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Heading for surgery

Posts: 15
Joined: Feb 2011

I haven't been on this forum very much. I was diagnosed with PC in January,2011 with a PSA of 4.9. Had two biopsies that confirmed Gleason of 2+2=6 in 2 areas. Six months later had another biopsy which was the same. I was told to wait 6 months and return to PSA and exam. In Novenber, 2011 PSA jumped to 7.4, but DRE normal. I took 2 weeks of cipro and went back after Christmas, December 27 and PSA had come down to 6, so we biopsied again and found 1 more area 3+3=6 and 3+4=7. Doctor feels it is confined, but feels we needs to get it out as soon as possible.

February 1, 2011 LLB 6 (3+3)
LMB 6 (3+3)

April 1, 2011 (same as above)

December 28, 2011 LLB 6 (3+3)
LMB 6 (3+3)
LLM 6 (3+3)
LMM 7 (3+4)

Also on this last biopsy "Perineural invasion is present, new cancer was 1MM.

Any thoughts?

hopeful and opt...
Posts: 1636
Joined: Apr 2009

was found in December 2011.

I strongly suggest that you get a second opinion from a pathologist who specializes, an expert in the field to confirm these results before you treat.

Additionally if your life expectency is less than ten years you can consider active surveillance.

I wish you the best.

Posts: 15
Joined: Feb 2011

I live in Houston, Texas. My urologist is well-known all over the country. He is a guest surgeon at Johns Hopkins at times. He has been around a long time. His pathologist has been with him for several years and she was recruited from M.D. Anderson here in Houston. My wife was with Baylor College of Medicine for many years and she knew him during her tenure there. I have no doubt that he has done many of these surgeries, and I'm positive he is not recommending this because he just wants to do another one. I am 64 years old, so basically he said that as my years increase I will be limiting surgery options, and now I am in good health and certainly hope to live more than 10 years. My Dad had prostate cancer, didn't get treatment until too late and I'm thinking he got it around 64 like me. He lived to 79, but was very ill in the last few years. I don't want to go there. Thanks for your suggestion.

Kongo's picture
Posts: 1167
Joined: Mar 2010


I echo others who are sorry to see the apparent progression of your disease.

Despite your personal ties with your urologist and his sterling credentials, you owe it to yourself to get second opinions on both your biopsy slides and possible courses of treatment. As you will know from your research over the last year there can be serious side effects following surgery.

Other treatments like radiation have as good (on whole) or better (depending upon the type of radiation) as surgery but without risking incontinence and ED. Of course, the choice is entirely yours and we will all hope for a successful outcome whatever treatment you decide upon but a consult with a radiologist using IMRT, SBRT, IGRT, or proton therapy will give you a broader understanding of the treatment options for this disease.

64 is about the average age for a PCa diagnosis. Your 3+3/4 is easily treatable by a number of methods and "getting it out" is not necessarily the best option.

The perineural invasion simply means that there was cancer detected near and in the area where the nerve bundles that surround the prostate are. Prostate cancer seems to like this area. PNI might make "nerve sparing" surgery more difficult and I would seek a very frank and candid discussion with your surgeon on this so that you understand what losing those nerves (if it comes to that) is going to do to your sex life.

All the very best to you.


Posts: 230
Joined: Jun 2009

Jimmie, I had radical prostatectomy 2009 when I was 62. I think you should explore your options and discuss this with your urologist and/or oncologist. Write down all your questions prior to doctor appointment and insist they explain anything you do not understand. You do not have to make a decision in the next week because your PSA is not very high. I would be looking at surgery, radiation or whatever you decide is the best treatment plan and consider doing something within the next 3-4 months, depending what your doctor recommends.

You have different options and only you can make the decision that you feel is the best for you. Another thing to decide is do you want quantity of life or quality of life.

I wish the best for you. Go forward into this with a positive attitude.


Posts: 193
Joined: Aug 2006

With your personal family history I understand that you are convinced that immediate primary treatment is your choice. Nonetheless, I hope you will speak with a radiologist and a medical oncologist about your choices and prospects. The radiologist will speak from his experience and the medical oncologist, especially one who has good experience with PCa, will give a less biased view that is not colored by his own treatment specialty.
You have the luxury of time and your location in Houston is full of top people in all areas. Use them.
Regret is a painful teacher.

VascodaGama's picture
Posts: 1871
Joined: Nov 2010


There are all reasons to think that you will live longer than the 10 years you wish. The diagnoses you present does not indicate your cancer as highly aggressive, and you are “in good health” and young.
I do not know about any other health factor but your life expectancy is over 20 years. Hopefully you do not get stricken by something else.

Your doctor may have recommended going through the treatment the soonest because of your family history with PCa. I agree that to wait another 5 or 10 years would not secure you a better outcome and looking for a cure now is a better choice. However, you got enough time to investigate on the pros and cons of the treatments before deciding. You should also get more tests/image studies to verify for metastases.
Can you tell us what is your clinical stage?

Both, surgery or radiation can give you similar successes and both have risks and cause side effects. You should get acquainted with the ones that you could not live with or without.
Getting the treatment done by good practitioners at good facilities tend to provide better results.

I would prepare a long list of questions for your next meeting, particularly in regards to the outcomes (possibilities of failure included).

I wish you the best outcome and long lasting years free.


Posts: 15
Joined: Feb 2011

When my urologist told me about the new 3+4 GS, he didn't mention a grade. The first biopsy which found GS 6 in each core was T1c. What concerns me is this perineural invasion, can this stuff continue to invade the nerve bundles if it already has? I would think I need immediate therapy to prevent additional spread.

I'm trying to understand what on the Gross Summary on biopsy report - LLM, size of sample (#blocks - 1, #Pieces - 4, Length (MM) - 2-11. THen is says the tumor focus is only 1mm. How do they decide that this perineural invasion is present is there?

Posts: 79
Joined: Nov 2011

If you have made up your mind to have the surgery, that's fine. I wish you well. However if you are still debating on the treatment options, I strongly urge you to get a second opinion on the Path as well as on the treatment options on Brachy/Radiation vs Surgery with a Med/Rad Oncologist. I believe most of the malignant foci were probably present all along over the 12 month period. So,in my humble opinion waiting a couple of months to get second opinions shouldn't really hurt.

VascodaGama's picture
Posts: 1871
Joined: Nov 2010


Your doubts should be included in the List of Questions to your doctor. He is the one that can better explain on the details of the Path report. You can even call his office to inquire on those items not clear to you. Do not be shy when confronting him or his nurses. Be the “commandant” of your boat.

Regarding your question on the report; they write about the percentage/volume/ of cancer found in one needle as been of 1 millimetre in length. This is very small but the presence of cancer have bigger significance, particularly because of the implications PNI has when classifying your status; Contained against Localized.

The famous Dr. Alan Partin (well known physician for his nomograms “The Partin Tables” to predict recurrence after surgery; http://www.prostate-cancer-radiotherapy.org.uk/glossary/Partin.htm) explains in detail the “danger” of perineural invasion (PNI) with regards to local metastases, in his study (2000) published by PubMed;

The conclusion done by another famous pathologist Dr. Epstein (from the same famous team with the surgeon Dr. Patrick Walsh at Johns Hopkins) on PNI says this;

“PNI does seem to confer an increased risk of extraprostatic extension of tumor. However, in a previous study, Epstein and associates1 found that men with isolated extraprostatic extension at radical prostatectomy had a 41% to 77% likelihood (varying with Gleason score and margin status) of biochemical recurrence- free survival a decade after surgery. Thus, the increased extraprostatic tumor extension posed by the presence of biopsy PNI should not serve as a contraindication to radical prostatectomy.”

The above reports are old but they still stand as recommendations from AUA followed by urologist around the world. One should think that they may be biased through surgery. In any case, there are patients who have been diagnosed with PNI and did surgery successfully.

Medical oncologists classify as “Localized” (not contained) cases where prostatic extensions are present. In such diagnoses, radiation of the prostate and surrounded areas (perineural) and of the lymph nodes at the iliac may give wider guaranty of a “proper clean up”.
Back in 2000 (my times) the equipments for administering radiation were not so accurate in comparison with the modern ones, and used to cause nasty side effects. Open Surgery was preferred and called “the golden treatment”, but nowadays newer modalities for delivering radiation and superior equipment can replace that golden stand and accomplish equally good.

An upmost step in the process of prostate cancer is to get a proper diagnosis. That will lead to a better decision on a treatment and therefore to a better conclusion.
You could try to investigate more about the presence of extra capsular extensions through a series of tests and image studies. Classifying you as Contained would be a relief and peace of mind for your decision in “Heading for Surgery”.

The typical CT and MRI scans are not good enough to find small tumours (metastases) of less than 2 mm in size. Newer modalities of MRI with newer contrast agents and higher resolutions (tesla 3) can give better lookouts of our insides. The extent of Perineural invasion can also be judged with a colour Doppler which shows blood vessels activity at the areas of the buddle nerves, were you have been diagnosed with the cancer.
Another newer image study reported to identify cancer at the lymph nodes is the USPIO MRI with feraheme agent. You may find details typing its name in a net search engine and in past threads of this forum.

All the above tests may come negative but they would provide you with the answer you are looking for and they will serve you as reference data base for any future development.
For understanding about biopsy and diagnosis you can read this;

I hope my insight is of help in your quest.

The best to you.

Posts: 807
Joined: Mar 2010

Based on the info you've provided, you have PCa with a Gleason 7 and PSA 7.4. This still considered early stage PCa (T1c or T2).

You do NOT have to have surgery to kill this type of cancer. There are radiation treatments, including CyberKnife, IMRT and Brachytherapy, which can do the job without needing to "cut" of the prostate. Frankly, surgery is the most risky and detrimental method of treatment for PCa and it is in your best interest to consider other methods.

If you're wondering what the risks of surgery are, I urge you to read the following article, which makes them quite apparent: http://www.hifurx.com/prostate-cancer/prostate-cancer-after-effects.

I highly recommend CyberKnife or High Dose Rate Brachytherapy as alternative methods of treatment. Take the time to investigate them.

Good luck!