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Robotic prostatectomy, now radiation? Outcomes?

sportguy
Posts: 2
Joined: Apr 2010

Age 57, robot protatectomy 2 weeks ago. Still feel very rough - maybe have a uti, going tomorrow for a urine check
Pathology report - pT2a - unilateral involving 1/2 of one side
perinueural invasion present (this is not good)
lymph-vascular invasion not present
gleasons 3 & 3
tumor involved less than 2% of total prostatic volume (original bx one 1 of 12 cores +)
tumor focally involves the resection margin (know this is not good)

The surgeon glossed the topic of radiation at the first postop visit - said maybe "later" we'd consider radiation.

My wife is a nurse - she has an inside track and has already spoken with a radiation oncologist - the recommendation here is radiation for 7 weeks

I went for a cure with surgery but the location of the tumor puts me in a position of what to do now. I did the robot for the best chance of avoiding incontinence and impotence.

Now I'm wondering if I was lucky enough to have accomplished that with the surgery what are my chances after radiation? Looking for honesty here guys - thanks

Trew
Posts: 891
Joined: Jan 2010

I'm a T4. Gleason was a 9 (5 + 4). - I had surgery, Positive bladderneck invasion that lead to hormone shots, and then radiation. You want to be as dry as you can get before you start that radiation stuff. Seriously, your numbers don't sound that bad to me. You discuss the impact of radiation on continency with your uro before deciding anything. From my expereince you have 6- 9 months to decide on radiaiton. Get dry first- that should be a very high priority.

bdhilton
Posts: 752
Joined: Jan 2010

I am 55. I believe that the medical community sometimes “over treats” for malpractice insurance… Having said that My surgeon (William Catalona) and my Urologist recommended adjuvant radiation in the first 90-120 days since I had a positive mid right margin, Right Seminal Vesicles involvement, Perineural Invasion on my pathology report based on initial studies showed that adjunct radiation with positives margins were showing better results…
You do not mention positive margins. Do you have positive margins? If you do not have positive margins then from any study I have read you would be wasting your money, time and radiation. ….I am not your doctor and this is what I am doing below, etc….and we are all different….

However, after I got my first PSA back at Zero in April I talk with my Urologist and he agreed with me that if he were me he would wait to see a rise in my PSA before I elect to have radiation because you are better off if you do not need it …so you are damned if you do and damned if you do not…but seriously it is a percent or so difference if you catch the rise under .02 between adjunct vs salvage…but the most interesting thing I have read in these studies is that if your margins were negative then this local radiation therapy is not going to help you…Anyway I still have about 33 days to think about this…but right now I am leaning on waiting and keep my excellent diet and exersie program as it is obvious that radiation is not good for you…. Hope I can but will do what I believe in necessary …I hate this PCa

The best to you plus yoiur results do not sound aggressive at all...so a bit confused with the information that you have provided

Post Surgery Prostatic Cancer Staging Summary:
Tumor Type: Acinar with Focal Ductal Differentiation
Gleason Score
Primary + Secondary: 4+3=7
Tertiary: Pattern 5
Location Main Tumor: Prostatic Base
Location Additional Tumor Nodules: Left Apex, Right Apex, Right Mid, Left Mid, and Left Base
Extraprostatic Extension
Focal (<2 Microscopic FOCI): N/A
Established (Extensive): Present and Extensive
Margins
Apical Margin: Free of Tumor
Bladder and Urethral: Free of Tumor
Other Surgical Margins: Positive, right mid Prostate
Seminal Vesicles: Positive for Carcinoma
Location, If Involved: Right Seminal Vesicles
Perineural Invasion: Present
Lymphatic/Vascular Invasion: Not Identified
Total Lymph Nodes: 2
Number positive: 0
Tumor Volume Approximately 18%
Tumor (T): pT3b
Metastasis (M): pMX
Nodes (N): pN0

mrshisname's picture
mrshisname
Posts: 186
Joined: Feb 2010

his post said that the tumor focally invades the resection margins - so yes, I think he had positive margins...
Glad you are here with your sage advice. Lead on McDuff!

bdhilton
Posts: 752
Joined: Jan 2010

Thanks Nurse Mrshisname... I get concerned sometimes with the intent of some the medical community with treatments recommendations to my PCa brother... As you know we all ran into snake oil sales people pre surgery not concerned with what was best for us but their pockets...

142
Posts: 169
Joined: Dec 2009

They will probably wait for a PSA test at about 8 weeks out before having a serious discussion about radiation. Take it easy until then, stress does not help healing much.

If they do suggest it, as in my case (I am at 26 of 39), they will probably want to wait for 18-20 weeks post DaVinci before starting anything. Healing can be impacted by radiation, so you want to have all the internal parts healed before starting.
My doc waited a few weeks longer, hoping the incontinence would get better, as he is of the opinion that radiation can cause the incontinence improvement to slow or stop.
Some will post that your incontinence level is frozen or gets worse with radiation. My doc would not go as far as to say that, as we are all different, but mine has worsened a bit.

I can't discuss ED - they had to take both sets of nerves, so that is a given for me.

Your numbers are generally good, much better than mine (same age, G 4+5, multiple EPE, multiple positive margins).

I would again suggest taking it slow and easy for the next few weeks, walk as much as you can for exercise; I guess your cath is out now, so do the kegels daily. Work on what you can control, and don't fall prey to PSA anxiety. It will be what it is regardless of how much you think about it. I'll wish you a bit fat 0.

ob66
Posts: 214
Joined: Apr 2010

Post op Gleason 3+4, Stage 3, seminal vesicals involved and removed, perineural, but no extension of tumor (encapsulated). Surgery last June 5. PSA was .05 for nine months (the first two regular, the last and ultrasensitive). Then PSA went up slightly to .07 (ultrasensitive). Since the incontinence remained at a low level an AUS was done first (May 10) and yesterday I was simulated for radiation and tatooed. Meantime I took Casodex and Lupron to temporarily combat the rise. The belief is that the CA cells giving this slight rise are most likely in the old bed of the prostate, thus the radiation therapy. Personally, I wish I could have done radiation last summer, but the incontinence precluded same. So now we move forward to attack which I like. A lot of research coming out suggests that if you are Gleason 6-7 or above, that radiation in concert with surgery is the treatment of choice. Hope this helps.

bdhilton
Posts: 752
Joined: Jan 2010

I agree (how I interpret the studies) that most of the new research coming out believes that radiotherapy is best suited after surgery for T3 patients with positive margins and extracapsular extension because they are more likely to have a tumor recurrence in the bed of the prostate gland…. In addition the timing of adjunct or salvage radiation when PSA levels were less than 1 produced better results

However, I choice to believe that it is better to wait until you have a rise in your PSA be it your first PSA test after surgery or 20th. Also as far as the seminal vesicle invasion (SVI) (which I have) we might benefit from radiation (adjunct/salvage) from what I get out of the studies here additional studies are necessary to examine survival outcomes following radiation because studies have found that patients with SVI have significantly higher progression rate with observation alone….

Bottom-line I personally do not want radiation unless I have to have it (so I am not overtreated) so damned if you do damned if you don’t but with postoperative radiotherapy, the earlier the treatment, the better, but current evidence suggests that not much is lost by waiting to see if the PSA level rises and then instituting radiotherapy right away (per William Catalona)

ob66
Posts: 214
Joined: Apr 2010

Hope I quote this correctly, but Tuesday I was led to believe that in patients with Stage 3 or higher that surgery with radiation have a 75% survival rate while those who don't compliment it with radiation have a 41% survival rate. Now obviously, these rates would be skewed by the degree (Gleason 6 vs. 9) and stage (III vs. IV), but nevertheless give the rational for consideration of radiation in concert in such cases. Then again, what does survival rate mean?? I suspect you finally die from something other than your prostate cancer, but I am not sure of this.

sportguy
Posts: 2
Joined: Apr 2010

Thanks to all for the input - I failed to mention my PSA's - in 2009 it was 1.7 and dropped to 0.8 in early 2010 - my family doctor did a digital exam and felt something abnormal so that is where the road began. While others can use a PSA to guide decisions I don't think I can. I am only the second patient in 28 years my surgeon has had that has prostate cancer with a low PSA - I guess I am lucky it was detected before it spread for sure

randy_in_indy's picture
randy_in_indy
Posts: 493
Joined: Oct 2009

Just wanted to chime in on the "perinueural invasion" Just about 100% of all prostates with cancer have that as it's refering to the nerves that are contained inside the prostate capsle not on the outside. I had it and still now 6 months later have no detectable PSA after my da Vinci. Not sure what the meaning of the resection comment is but hoping even if it was an outside the prostate positive margin that they got it all and you join the Zero PSA Club!

Randy in Indy

bdhilton
Posts: 752
Joined: Jan 2010

I guess you could get those numbers if you just read one study ...but my URO supports what I am doing as prudent....best to all

ob66
Posts: 214
Joined: Apr 2010

bdhilton: I am having trouble reading between the lines on your two posts from yesterday. As I am committed to radiation (Post da Vinci) your answer will not effect me, but maybe others on the board. At 9:00am you seem to concur with the research that suggests higher gleasons and stages should have radiation, but then in your second paragraph speak in the "I", as in what you want, not necessarily what research suggests. Then in your second post you cite what "I am doing is prudent". As you cannot emote on a post, this is in no way meant to be contrary, but investigative. You have made some other comments about doctors padding their wallets, so I think the distinction is important.

Everything I have heard since I had my daVinci one year ago next week, is that if you have "high numbers" and want the best chance for the long term, that daVinci plus radiation is the best, the sooner the better. Just wondering if you had supporting "science" to dispute what I have heard. We all have our preferences. God only knows I wish I never had a radical prostatectomy, nor an AUS placed. But that is my reality. I have chosen, based on the best science I can find, radiation. Now, in my case, my desire to Kill the CA may reflect my bias, but I think the science is new and sound. JMHO, and Cheers

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Kongo
Posts: 1167
Joined: Mar 2010

One thing about this discussion that puzzles me is why one would opt for surgery knowing that there was a strong liklihood they would follow up with radiation. The 10 and 15 year numbers for almost any form of radiation are comparable to surgery but generally have few complications.

I consulted with several specialists including urologist surgeons, oncologists, and radiologists and all of them indicated that if there was evidence that the cancer had spread beyond prostate capsule (high numbers might be an indicator) they would not recommend surgery but would go straight to radiation or hormone therapy or both.

It makes no sense to me to remove the prostate knowing that you were going to follow it with radiation.

What am I missing here?

ob66
Posts: 214
Joined: Apr 2010

In previous posts I have indicated that my CA did NOT extend beyond the capsule. My understanding of the most current research in the last 2+ years is that if you want the confidence of the greatest "kill" when you have higher numbers you do surgery + radiation. Note: encapsulated with high numbers (gleason 6 or 7+, Stage III or higher). Admittedly, I like the concept mentally----kill dem CA bugs. Just tossing it out there to see if others have heard differently. I had surgery for the belief (that was confirmed) that the CA was within the borders of the prostate, and the coming radiation to give max kill. I chose not to have radiation first, for I like the idea of the CA cells excised. Hope this helps.

BRONX52
Posts: 156
Joined: Apr 2010

USUALLY, SURGERY IS NOT RECOMMENDED IN MOST CASES, IF YOU ARE CINICALLY STAGE 3 OR 4 WITH A HIGH GLEASON. I WAS A CINICAL STAGE T1C---GLEASON 3+4--7, WITH A PSA OF 5.1. AFTER DAVINCI SURGERY IT WAS UPGRADED TO T3A, EXTRAPROSTATIC EXTENSION AND POSITIVE MARGIN. EIGHT WEEKS AFTER SURGERY I STARTED IMRT AND CURRENTLY HAVE 3 SESSIONS REMAINING FOR A TOTAL OF 38. SO IN MY CASE IT WAS SURGERY PLUS RADIATION. IF THE SURGERY HAD TURNED OUT WITH BETTER RESULTS I DON'T THINK RADIATION WOULD HAVE BEEN RECOMMENDED. I NEVER EXPECTED TO HAVE RADIATION BUT WAS TOLD PRIOR TO SURGERY THAT IT WAS A POSSIBILITY DEPENDENT ON THE PATHOLOGY REPORT.

RDC
Posts: 1
Joined: Dec 2010

I had Divinci Oct 18th 2010 based on biopsy of 3+3 (6) 5% one core. Turned out to be 3+4 (7) with positive margins,and a (6) at the margin, extensions, perineural invasion, and I am not sure about the right and left lymph nodes. I have had two pathology reports from different labs, one said right and left (not sampled) the other says "right and left positive for prostatic adenocarcinoma". Anyway, I have been told that radiation is now the standard of care for me or anyone in my situation I guess. Really don't want to do it, but I do want to do what is best. Hard to know with all of the different doctors opinions, better to get it from the guys who have been in the battle. Good Luck everbody

bdhilton
Posts: 752
Joined: Jan 2010

My pathology after surgery said that I’m a T3b (Gleason 4+3) with right seminal vesicle involvement, extraprostatic extension, positive right mid Prostate margin and my Adenocarcinoma involved approximately 18% of the prostatic volume ….with that said and extensive research into my specific treatment and underlying potential issues I elected with my oncologist blessing to forego adjunct radiation and will consider salvage radiation if I have a recurrence.

However you are 100% right about the current trend with have adjunct within 120 days after surgery for guys with some of the complications you and I mention. I would listen to my oncologist carefully, pray (if you are a believer) and sort out what is best for you…

What I find most important to point out for guys coming in here and going through the treatment selection process is how your initial biopsy finding were (low risk) to your actual post surgery (high risk and some other potential complications)> You never will know what degree of cancer you got unless you get surgery but then again it might be a blessing not to know…

This whole PCa thing is a something I for sure did nto sign up for…and for me I have a PSA test next week (almost 10 months for the 4th since surgery) and perhaps I will be blessed with another “0” or the road will turn again in this journey…I still hate the week before and waiting for the results…but it will be what it will be and I’ll take it from there..

Best to all and happy holidays

bdhilton
Posts: 752
Joined: Jan 2010

Kongo…

If I remember correctly you have a low “Clinical” grading of cancer and you will never know what the actual grade is because of your treatment choice that you believe is the best for you and that is great to believe in your treatment choices.

I have read and have talked with many guys that go into surgery with a low and local “Clinical” grading to find out that they have more aggressive cancer. In fact about 90% on clinical grading is increase after the surgical pathology findings and in reality 1/3 of the surgery end up having to have some form of radiation and from what I have read and been counseled on with PCa treatments say that surgery is the best option for local cancer as you have a better survival odds with surgery then radiation if needed that the radiation with surgery…. Also most guys that choice radiation have health related issue and cannot handle the surgery or it is far more advanced and surgery is not an option….

I do not believe any one here had surgery (or should have) if the cancer was not local based on Clinical grading…I am pretty sure that is unaccepted medical practice…

Personally, my “clinical” staging that was done at one of the best treating and research hospital in the world was a local grading (PSA 2.8, Gleason 3+4 and TB2)and I ended up with a higher grading etc…

My step father was a “Harvard” physician and director of one of the major research medical schools in the USA (even has an illness named after him). He selected radiation as his treatment some 15 years ago because “he was to busy to be bothered with surgery…”…He died from PCa this January his PCa silently spread to his liver and pelvis area. He was the one who convinced me to get surgery…

Again, I am happy that you are moving forward with the treatment you feel will give you the best benefits but they all come with risks and side effects….From my research there are no “shortcuts” all the treatments suck….G*d bless you in your journey…

My best to all

SRVR
Posts: 11
Joined: Dec 2010

That's a mystery to me as well. I'd guess that those who are facing this scenario didn't know that cure rates of low grade tumors treated with surgery or radiation are about the same. So why put yourself through the pain, risks, and side effects of surgery if there's no evidence that it matters?

A radiologist won't send a patient to a surgeon prior to radiation treatment. Radiation kills cancer.

A urologist will only recommend radiation after surgery to correct a failure or cover anything he might have missed. Of course it improves cure rates, radiation kills cancer.

Even an expert surgeon could leave a drop of cancerous blood in the prostate bed after slicing out the gland. Radiation treatment solves problems surgeons create.

If you haven't had surgery yet, consult a radiation oncologist. Look at every alternative.

bdhilton
Posts: 752
Joined: Jan 2010

So you believe that “urologist will only recommend radiation after surgery to correct a failure or cover anything he might have missed…” and that "Radiation treatment solves problems surgeons create..." interesting perspective.

ob66
Posts: 214
Joined: Apr 2010

A pretty emphatic condemnation about "a urologist" SRVR. Having practiced in the health care field for over 36 years, I would prefer to think our physicians are practicing to cure us rather than cover their backsides. My preference was surgery. My surgeon and my RT and my oncologist all worked together to gain the best result. It isn't over yet, as it never is with CA, but I am so glad I have faith in my team (not blind faith, by the way). You must have some pretty big worries in addition to your CA, if your trust is as you have indicated. And to think there is only one solution as in your last sentence is scary at best. It is good that you like the choice you made, but it is not necessarily best for everyone and every situation. JMHO.

SRVR
Posts: 11
Joined: Dec 2010

Sorry for all the drama there. I was commenting on and agreeing with Kongo regarding his "conundrum" remarks. He's dead on.

During my proton treatment I spent a lot of time with about 90 other men in treatment. About 20 of them were there for salvage treatment for surgery that had failed. One was done at Johns Hopkins, many were DaVinci patients.

Those who were there for salvage treatment were overwhelmingly disappointed that they had not consulted a radiologist prior to surgery. It's natural for the urologist that discovers our cancers to be confident they can cure it with surgery. Unfortunately many men stop looking for solutions past that and go through surgery with all it's side effects only to end up in worse shape.

If anyone on this forum is considering surgery, consult a radiologist first. Not for just conventional radiation or bracytherapy, but also for proton, cyberknife, and toma therapy.

Surgery, robotic or open, is highly practitioner dependent. Even the best surgeons don't get cancer out all the time. If you've decided to have surgery, check the track record of your surgeon. His level of experience is crucial to your long term survival.

Read Kongo's cyberkife testimony. It's motivating and encouraging. My proton treatment left me with no side effects and was completely painless. Don't settle for surgery because you haven't done any research. Have surgery because it's the best course of action for you.

Swingshiftworker
Posts: 620
Joined: Mar 2010

Amen to that!!!

I chose CK to treat my PCa for basically the same reasons as Kongo and others -- the same prognosis for recovery as surgery without the substantial recovery time and risks of sexual and urinary dysfunction commonly associated with surgery.

Why any man w/PCa would subject himself to surgery w/o considering radiological options is beyond me but, if he chooses surgery, he should (as you suggest) definitely take great care in investigating the skill and experience of the surgeon who is going to do the job.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

It’s natural for men who have chosen a particular method to treat their prostate cancer to be emotional and defensive about their choice and thank you for sharing your view of the advantages and outcomes of your proton therapy. Your story may well help a fellow victim of this disease to reach an informed decision about his own treatment. But like politics and religion, some feel that the only correct choice is the one they made and that everyone else is wrong; hence the drama. So develop a thick skin and keep making your points.

I completely agree with your views about independently seeking second opinions on how to treat the diagnosis our initial urologist delivers. The decision we make about treatment may well determine the length of our lives but will most certainly affect the quality of our life for however long we have left. Not to consider all the potential options available is, to me at least, foolish. Doing your research and consulting with different specialists doesn’t guarantee a life free of cancer or adverse side effects, but at least it should avoid the “if only I had known” syndrome that is possible for men who do not investigate alternatives.

I’m glad your proton treatments went so well and hope that you continue to enjoy a high quality of life

ob66
Posts: 214
Joined: Apr 2010

SRVR, you must understand that not everyone was waylaid by a urologist. One size fits not all. In my case I consulted with a urologist, a radiologist, and an oncologist before I made any decision. I did not want radiation as a first choice (rightfully, or wrongfully). I wanted the CA cut out of there. Period. It was and hopefully is cut out of there. My MDs however, have been very careful, and when my PSA (ultrasensitve) rose from 0.05 to 0.07 after 4 tests and ten months (a rise that many would say is within limits), these medical people decided I would best have RT. I did, and completed same in August.
To conclude, I do not see my daVinci surgery as a failure. I see my RT as an extension to further control the CA, and my usage of lupron plus diet (no meat, no dairy and as little sugar as possible) as being as proactive as I can. The only disagreement I have with your writings is the simplicity of your conclusions and treatment options. What is good for you is good. What is good for me is also good. I hope it remains that way for both of us. I was offended a bit, when you implied less than ethical reasons for treatment recommendations by MDs. I believe, as in all lines of work, there are bad apples, but to base premises in medicine on that, is scary at best and a stretch at worst.
Finally, I think Kongo's writings are the most excellent thing about this forum, other than the general sharing that goes on. But I think the conundrum of which he spoke related to not understanding why anyone would have surgery with the idea of having RT after. I did not approach it that way. It unfolded, unfortunately. But I am very good with where I am right now. Cheers, and Merry Christmas to all, and all the help I have received by tuning in here.

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

ob,

You're correct in summarizing the gist of my conundrum question seven months ago. Given the information available in the posts, I simply did not understand the reasoning of going for surgery with the expectation of quick follow-up with radiation...which I took to mean they had assumed the cancer had already escaped the prostate. It's not that I was necessarily against surgery, it's that I didn't see enough information to be able to look at it and say, "Oh, so that's why they're doing that..."

In my non professional opinion, choosing surgery is a preferable and effective option for many men depending on their pathology, personal choices, and long term expectations. Worldwide, it remains the most common treatment choice and the doctors who recommend it and practice it are, for the most part, not dummies. In most cases, it works out fine. Sometimes, like in your case, despite all our best expectations and studied investigations, sh*t happens which causes us to adjust our approach to treating prostate cancer.

As a result of my own journey and continuing study, I've learned that there are seldom any simple answers to these questions and that the "rules" about prostate cancer are ever changing and elusive. For example, in another forum today I read a post from a recently diagnosed man with PCa who had just completed DaVinci surgery and his advice to the world was essentially: "I had DaVinci and it worked for me therefore it will work for you. Don't worry about it." These types of statements make no sense at all to me and ignore the vast differences in our individual cancers, preferences, priorities, prognosis. I think if it works for you, then good. If it doesn't, you have our sympathies. Hopefully, men make their choices based on the type of rigorous analysis that you did but even then, you have to prepare for alternative outcomes.

Merry Christmas to you as well!

lewvino's picture
lewvino
Posts: 1004
Joined: May 2009

Kongo, Interesting post and I enjoyed reading it.
Yes you are correct that many will make statements such as "I had such and such and it worked for me".

Education is key to fighting this but many do not want to bother with the education and go with what ever is recommended. There are so many variables to the equation, PSA, Gleason, spread, age, family history..... and the list goes on.

On my search I looked at every option in great detail. I'm sure that I would have had success even with other options but I was looking for a long term plan with my Gleason 7. When my father was diagnosed he had Gleason 6 and took a different plan of attack. He is 13 year survivor!

Best christmas wishes to all that fight cancer in any form.

Larry

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