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PSA 74 and Gleason 3+4

newuser
Posts: 9
Joined: Jul 2011

Hi , My Dad (68 yr old) got PSA of 74 and biopsy with Gleason Score of 3+4=7 .Report says Adenocarcinoma Prostrate and presence of perineural invasion with mild inflammation.Total linear mm of caricnoma is 99 mm .The proportion of total issue involved by tumour is 72%. What should be best therapy ? Any advise , comment....

VascodaGama's picture
VascodaGama
Posts: 1562
Joined: Nov 2010

New

I would suggest your father to check for metastases before deciding on a treatment. Volume and PSA are high but the Gleason score is that of an intermediate risk case for recurrence after a radical treatment. In my case I had high PSA (22.4) and voluminous cancer with low risk Gleason rate (2+3) and negative image studies (MRI+Bonescan), but after surgery I was diagnosed with micro-metastasis. This could be the status of your father too.

You could request for image studies such as; eMRI plus Bone scan (the traditional pair), TRUS with colour Doppler (which could ascertain for existing blood vessels supplying any cancer peripheral to the prostate) and Ultra-small Super Paramagnetic Iron Oxide particles (USPIO) MRI (the best test for checking for metastatic cancer at the lymph nodes).

In case of negative image studies your dad’s case could be considered contained, to which surgery or focal radiotherapy (cyberknife, proton beam, bracky) is advisable. If micro-metastases are considered then hormonal treatment is the most recommended.
Some doctors suggest added IMRT radiation to a wider area of the pelvic including lymph nodes (the gates for metastases).
An excellent diagnosis leads to successful treatments.

All treatment have side effects which your father should be aware of. Many are nasty and permanent which takes patients to include this item in the decision process when looking for a treatment.
You can read in the net about side effects details googleing this sentence “side effects from treatments for prostate cancer”.

Welcome to the board.
The best to you both.

VGama

robert1
Posts: 82
Joined: Apr 2011

Hello newuser:

First of all, the odds are very good that your Dad will be fine. The advice given to you from VGamma is excellent. We all need to know exactly what we are dealing with before deciding on a treatment choice. Assuming the cancer is localized to the prostae, your Dad will have several treatment options. At his age, surgery is most often eliminated from the short list of choices.

I do differ somewaht about your Dad's options assuming the problem is contained in his prostate. The Gleason 7 score puts him into an intermediate risk category where some of the newer and less proven treatment options may not be ideal. There is data available for treatment options for this category of PCa, so do your homework and beware of options that cannot supply you with 5 and even 10 year published cure rates for intermediate risk PCa.

The people on this board are very helpful. They certainly helped me.

Best wishes to you and your father!

robert1

newuser
Posts: 9
Joined: Jul 2011

Thanks Robert and VGama ! My dad is in India and doc suggested to go for Surgery.Removal of Prostrate withthe help of the Robot.

He did go thru Bone test which was clear.No sign of spread. Will try to find out if there are another test available there.

Thanks for everyone's support...

newuser
Posts: 9
Joined: Jul 2011

Any comment on Surgery using Robot...............

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

newuser,

Sorry that your family has to deal with this. I think you've been given good advice to date but I would seek second opinions before proceeding with the RP, whether or not you chose robotic or traditional open surgery.

You described that your father's pathology report indicated the presence of perineural invasion. You may wish to research the implications of that finding and its potential impact on overall treatment. When seeking second opinions I would definitely ask the doctors about the impact of PNI on the liklihood of recurrence following RP. It is generally thought that the presence of perineural invasion (PNI), particularly in Gleason 7 patients, is indicative that the prostate cancer may have escaped the prostate gland. If this has happened, removing the prostate won't curb the growth of your father's cancer and there is a good possibility that he will have to undergo further treatment options (radiation).

As others have noted, any treatment has a variety of potential side effects but when you begin to combine treatments (such as RP followed by radiation) the risk of adverse side effects goes up significantly.

I believe it would be worth the effort to explore a second opinion to see if radiation alone could potentially address your father's cancer at its present stage. At least if you go forward with surgery, you will have the peace of mind of knowing that you examined other options first. You should also be alert to the possibility of recurrence (determined by a risking PSA score after surgery).

If you do proceed with robotic surgery, I hope you can find a surgeon with considerable experience. Studies in the United States have indicated that a surgeon gains competence in the technique after a few hundred operations. Obviously, the more experience your father's surgeon has the better the odds that he will swiftly recover with the best odds of adverse side effects.

Good luck to your family.

K

newuser
Posts: 9
Joined: Jul 2011

Thanks Kongo!

Yeah , cancer has spread around 7% outside the P gland. But doc says its better to get surgery first and then radition or hormone.There may be more impact doing the surgery after radiation.

I am wondering what should be the best route for patient with PSA 74 , G (3+4) , 72% P tissue shows Cancer with approx 7% PNI...

Surgery > Radiation > Hormone
Hormone > Radiation > Surgery
Surgery > Hormone > Radiation
Radiation > Hormone > Surgery
Hormone > Surgery > Radiation

Any specific order ....Different doc , different opinion .All BIG confusion............

mrspjd
Posts: 693
Joined: Apr 2010

Choices # 2 & 4, if even possible, are unlikely to be successful (were choices 2 and 4 actually recommended by a doctor? If so, what speciality?). Another viable PCa tx option to investigate and consider for intermediate/high risk, high volume PCa, especially when PNI is present and ECE (Extra Capsular Extension) is likely:

Hormone>Radiation>Hormone

Seek many opinions, especially an independent opinion from an experienced PCa oncologist; also from rad oncologists w/ current and modern up to date RT tx equipment, as well as from uro surgeons. Make sure all possible diagnostic testing is done to, FIRST, properly stage the PCa prior to any tx decision. Take time to investigate all. Look before you leap. You indicate: "cancer has spread around 7% outside the P gland" How was this 7% spread determined? What diagnostic test was used and did it identify where the 7% exists, i.e., seminal vesicle(s), lymph nodes, bone, etc.? Important info to know and understand when considering tx choices.

It's not just about which tx is best, it's about which tx has the greatest chance of success for mitigating dad's accurately pre-tx staged PCa, with the least amount of side effects for QoL.

newuser
Posts: 9
Joined: Jul 2011

I put those paths based on known 3 treatment but no doc mentioned those in particular order...

My Dad is India and docs there are advising for Surgery only . The 7% based on biopsy reports and it could be in lymphs.Bone test was clear for him.

India , Doc said Prostrate has to be remove because of growth/percentage of tumour present.

When I discussed with couple of Docs in USA , they recommend Hormone >Radiation should suffice and surgery may not be needed.

........waiting for right direction.

mrspjd
Posts: 693
Joined: Apr 2010

Vasco, Kongo and others previously gave excellent advice. Since parts of India are known to have sophisticated, modern and up to date medical/cancer tx centers, guessing that E-MRI, color doppler ultrasound and maybe even an USPIO MRI are available diagnostic tests. If those tests are not being offered, your dad needs to request them, especially considering the (incomplete) stats you presented for his intermediate/high risk PCa dx. Odds are that dad’s doc is an uro surgeon, hence the recommendation for surgery as primary tx. But it cannot be emphasized enough for intermediate/high risk, high volume PCa—-seek the full range of diagnostic testing available in order to clinically stage the cancer FIRST, then seek many add’l opinions from a variety of experienced & skilled PCa specialists before deciding on which tx protocol has the best chance for successful tx. Be sure each specialist (RP, RT, HT, etc) explains the wide range and intensity of potential tx side effects (immediate and latent) to your dad. And you both need to do your own research to ask questions in order to validate/confirm info given to you by doctors.

My husband’s PCa dx (last year) was similar to your dad’s. Locally advanced high volume non-mets T3 PCa. Low PSA but nodule found on DRE. He sent his biopsy slides out for a 2nd opinion report to a path lab that specialized in reading only PCa biopsies. Lab concluded G 3+4=7 with PNI, 9/12 cores positive at high percentages. Bone scan and CT w/contrast clean/negative (those tests usually don’t pick up micro-mets anyway). Since PNI is a red flag signaling that ECE is likely, he made arrangements to have an E-MRI and color doppler ultrasound. Both tests confirmed ECE spread to seminal vesicle; nodes “looked” clean (NED). This add'l info played a critical part in my husband's tx decision.

After tons of research and multple consults w/ a wide variety of medical PCa specialists in most tx modalities, he elected not to have RP surgery even though it was an option since he was qualified w/no preexisting health issues. He chose HT and 2 forms of RT as primary txs. The rationale for this decision is posted elsewhere in another thread.

There are several other posters on this board, some patients, and some partners of patients, who have posted about similar intermediate/high risk PCa dxs, but who chose other primary txs such as surgery (either RP or RRP); or surgery followed by either ART or SRT w/ or w/o HT. I suggest you read 4-5 back pages of ALL posts on this PCa forum.

Newuser, it is too soon to be making tx choices without first having add'l diagnostic testing to determine the extent of your father's intermediate/high risk PCa. The testing should be scheduled soon, especially with such a high PSA. The add'l info from these tests is required in order to make a tx choice that has the best chance of success using a primary or primary/neoadjuvant combination tx. Also, re the biopsy: It is important to know how many cores were sampled, how many cores postive and at what %'s.

If only we had a crystal ball to tell us what choices to make and predict the future…Until then, you, dad, and your family have the burden (as we all have had) of doing your own research and homework--a daunting but mandatory task for a PCa dx. Having been in your shoes, I know this is a difficult and scary time for you and your dad, especially trying to manage his care from a distance. Soon things will begin to make more sense and decisions, although challenging, will fall into place. Knowledge is power.

Good luck to you and your dad.

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

Newuser,

If your father's doctors can tell for sure that the cancer is outside his prostate, then why on earth do they want to do surgery? Removing the prostate will not stop the spread of cancer outside the gland and it tends to grow faster outside the gland than inside as the prostate gland surrounds cancerous clusters with a membrane that acts to contain the spread.

I would urge you to get a second opinion from another doctor that isn't so set on surgery in your father's case. If the pathology indicated that PCa was contained within the prostate, surgery might make sense for an intermediate cancer such as a Gleason 7.

Remember, it isn't the PCa in the prostate that kills us...it's the cancer that spreads to other organs.

I understand this is a confusing and difficult situation. I hope you sort it out.

Best to your family.

K

VascodaGama's picture
VascodaGama
Posts: 1562
Joined: Nov 2010

Newuser

If your statement “… cancer has spread around 7% outside the P gland…” is found to be correct, then your father’s doctor suggestion for a robotic surgery is baseless. Hormone therapy, or Radiation, or a combination of both, are the most recommended methods, as MrsPJD informs.
Check on this thread; (http://csn.cancer.org/node/215211)

I am surprised for the doctors’ opinion on; “growth/percentage of tumour present”. This is a past theory in predicting spread. Nowadays surgery as a means of “Debulking” is not considered proper at all. That used to be common practice in the 1990th because radiation (the alternative treatment with curative purposes) applied with the old type of equipment presented low rates of cure and the side effects were nasty and critical.

At present days, including in India, treatment of PCa in places of excellency use modern equipment (IMRT/IGRT) that can deliver radiation very efficiently with much lesser probability of critical side effects. Those “machines” are superb and the rates in terms of biochemical free survival are very equal (similar) to the rates in surgery.
Your father should aim into one only treatment that can assure successful results. Not into a “continuing” series of treatments.

I would add my layman’s opinion and suggest your father to get a second opinion from a different hospital/doctor where modern views are followed. As Kongo puts it “...it's the cancer that spreads to other organs that kills us”.

Hope your father finds a doctor he trusts.

VGama

newuser
Posts: 9
Joined: Jul 2011

Hi All : Thanks for all the support you provided to me and my family. My Father has sugery 2 months back and reports came back with result of 84% of Prostrate tissue was cancerous which was removed. No lymph node was found cancerous.(Whatever doc extracted and sent to lab).

After the surgery he was recovering well but approx one month later he got sever UTI and took interavenus antibiotics (ertapenem and niftas as the tablet ).He is better now .

After 2 month of surgery PSA is 1.35 .Doc said surgery was big and after another month it should go down below 0.5.

After reading lots of posting on this network , I am worried.

He is still having Urinary incontinence .

Any idea , how long does it take to settle down the PSA ?
Does high fever/UTI for one wk (one wk before PSA) could have impcated this PSA result ?

Please share your experience and knowledge .

Thanks!
B

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

B,

As discussed in responses to your previous posts, your father evidently had evidence of cancer outside his prostate. Removing the prostate, even with a very wide cut into the margins, was unlikely to remove it all. Typically, the half life of PSA in the blood stream is about 48 hours. I would be astonished if your doctor's prediction that it will move from 1.5 to less than .5 in another month came to pass. While there is a possibility that the surgical trauma could have caused some immediate PSA increase, I would be surprised if that was the cause at this point.

For men who still have a prostate, a UTI could be the cause for a rise in PSA but since your father has now had his removed, I would guess that the PSA results you are seeing now are caused by the cancer that was already out of the prostate before surgery.

the incontinence after surgery is common. Hopefully your father has been instructed about how to do kegel exercises and he is working on them but as long as he has these recurring UTIs it may be awhile before he regains continence. Older men often take longer to recover continence than younger men.

I don't know anything about the medical care network in India but if your father has the option to consult with other doctors on his condition I would suggest that you urge him to meet with them as soon as possible.

Good luck to you both.

K

newuser
Posts: 9
Joined: Jul 2011

Thanks Kongo ! Thats what I am worried about .Although Doc tried to take out all the extended tissue around prostrate but its still there.

My Dad is going to see a doc in couple of days .Let us see what does he suggest next.

I am not sure if doc will wait another PSA test/or some other test before next line of treatment.

Will keep you all updated.

Thanks!
B

VascodaGama's picture
VascodaGama
Posts: 1562
Joined: Nov 2010

PSA is “manufactured” by prostatic cells (benign and cancerous). After removing the prostate gland with the surgery, the PSA should drop to undetectable levels of less than 0.05. The body takes usually 10 to 15 days to clean-up any serum PSA. Your father’s status after 2 months with a PSA at 1.35 is indicative that the whole cancer has not been removed.
However, in your previous post above, you commented that there were “spread around 7% outside the P gland”. We can assume that metastases are present and producing PSA.

Your father’s doctor is not correct in assuming that the PSA will take three months to go down to 0.5. Most probably the PSA will rise and your father should follow with an adjuvant treatment, such as hormonal therapy, to stop the advancement of the bandit.
The doctor's good practice is questionable to me. I would recommend you to get second opinions from a specialist oncologist.

Biochemical failure is present and you should be looking for a salvage treatment. Try to research in the net typing this sentence “salvage treatments for prostate cancer after surgery”.
The fever may be a cause from an infection related to the surgery. Hope he gets better.

VGama

newuser
Posts: 9
Joined: Jul 2011

Thanks VGama ! I will ask my Dad to consult one more doctor. Now we need to see what is next line of treatment he should go for and how quick ?

Thanks!
B

hopeful and opt...
Posts: 1331
Joined: Apr 2009

see more than one doc to consider slavage treatment; a radiologist, an oncologist tht specializes in protate cancer.

You have received excellent adice and information from the posters at this thread, both before your father made a decision to have surgery, and now.

VascodaGama's picture
VascodaGama
Posts: 1562
Joined: Nov 2010

Newuser

In a Davinci surgery (robotic RP), doctors cannot reach easily those far areas in the pelvic. The comment on “Doc tried to take out all the extended tissue around prostrate” is traditional in open-type of RP, where they reach far and “scrap” with their hands. This is one of the main reasons to choose open over close (robot harm). The lymph nodes dissected in Davinci are close to the prostate gland but there are others where metastasized cancer typically hides. Radiation is usual recommended by doctors to reach the far areas including those lymph nodes, in situations similar to your dad.

The oncologist Dr. Charles Myers comments in his site a protocol of radiation with hormonal therapy. Your father could start now with HT and follow with IMRT as soon as he finds a satisfying decision.
He should inquire about the above protocol when consulting with the new doctors. You can read details typing “Salvage Radiotherapy with neo or adjuvant Hormonal therapy after Surgery”.
To listen to Dr. Myers videos type this “Recurrence after RP and Myers”.

Your dad can wait for another PSA, but without an adjuvant treatment or another logical explanation, the PSA will not alter the results. Surely his status would not be at a higher risk in three months. There is time for tests and research and make decisions on his future salvage treatment. Just do not let things running unattended.

Wishing you peace of mind.

VGama

newuser
Posts: 9
Joined: Jul 2011

My Dad met the doc about his report and what next ? He suggested to have another PSA in 4 wks to get nadir PSA level. Since his PSA was 74 ,he still thinks it may come down a bit.But he suspects the metastases as well. He is going to start with HT after the next PSA. Hope this delay will not impact his health.

Q: Usually for how long HT works ?
Q: Does he needs to take IMRT along with or that depends upon PSA ?

Thanks!
B

2ndBase's picture
2ndBase
Posts: 220
Joined: Mar 2004

Kongo is right on about there being no need for surgery. I had Gleason 9 and psa of 24 and the radiation killed all the cancer in the prostate. It won't make any difference in your life expectancy if you do surgery or radiation because neither one of those will do more than give you side effects. Take time to think about quality of life which is much more important than quantity.
My hospice oncologist told me that even the cancer that spreads won't kill me its just that the body becomes to weak to fight off something simple at the end . Trust me, he knows of what he speaks.

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