Pathology report in - should we commend with HT?

Pathfinder

Surgery completed this

Surgery completed this morning. It was open surgery performed in Shanghai.

At the moment my Father in law is doing ok. Still sleepy from anaesthetic. The doctor said his heart rate has been a bit low all day. We're not sure why that is, although nobody is treating it as a cause for concern at the moment. I'm assuming it's due to such a heavy surgery/blood loss.

We literally only had 30 seconds to ask one of the surgeons some questions, so unfortunately we didn't get much information and will probably need to wait until tomorrow for more details. 

We know that the seminal vesicles and lymph nodes were removed and there was no sign of metastases there, they surgeon said they were ok. 

They did say that there was some adhesion around the prostate due to 6 weeks of hormone therapy. And that's all he said. He didn't say if it was a complication or problematic for the future, so we're left wondering what that means for us and googling various info (and not finding much).

I understand HT can create adhesion around the prostate gland which can make it more difficult to cut. I'm worried the adhesion may make it difficult to cut any infected areas.

I have no idea why the initial hospital put my father in-law on HT for 3 months (of which he only completed 6 weeks due to us speeding up the surgery process) if there is the potential for adhesions like this?

Perhaps we're over-worrying on this, the doctor really only mentioned it briefly. But I'd appreciate your knowledge about this because there's very little I can find on the net.

Thanks guys!

VascodaGama

Pathfinder said:

Surgery completed this

Surgery completed this morning. It was open surgery performed in Shanghai.

At the moment my Father in law is doing ok. Still sleepy from anaesthetic. The doctor said his heart rate has been a bit low all day. We're not sure why that is, although nobody is treating it as a cause for concern at the moment. I'm assuming it's due to such a heavy surgery/blood loss.

We literally only had 30 seconds to ask one of the surgeons some questions, so unfortunately we didn't get much information and will probably need to wait until tomorrow for more details. 

We know that the seminal vesicles and lymph nodes were removed and there was no sign of metastases there, they surgeon said they were ok. 

They did say that there was some adhesion around the prostate due to 6 weeks of hormone therapy. And that's all he said. He didn't say if it was a complication or problematic for the future, so we're left wondering what that means for us and googling various info (and not finding much).

I understand HT can create adhesion around the prostate gland which can make it more difficult to cut. I'm worried the adhesion may make it difficult to cut any infected areas.

I have no idea why the initial hospital put my father in-law on HT for 3 months (of which he only completed 6 weeks due to us speeding up the surgery process) if there is the potential for adhesions like this?

Perhaps we're over-worrying on this, the doctor really only mentioned it briefly. But I'd appreciate your knowledge about this because there's very little I can find on the net.

Thanks guys!

Sticky fingers

The majority of surgeons in open surgeries do not like that feeling of sticky fingers. They do the cutting using the touch and vision trying to separate the gland without inflicting any injury to attached tissues. That glue like aspect caused by HT confuses the touch, in particular if any bump exists which would be targeted for dissecting. The worry is if the outer shell of the gland is cut freeing cancerous cells that could be glued to that sticky coat and left behind. Please read my comment above in regards to the negative of HT before RP.

This is just an added worried because the surgeon will vacuum the whole area carefully sucking the blood and any detritus before stitching up.
in regards to the doctor’s comment on the seminal vesicles and lymph nodes, that is an impression regarding the aspect these presented. Cancer cannot be seen by the open eye unless it is a sizable tumour. Typical affected lymph nodes present sort of bumps that could be made of small tumors or just blood detritus.

The gland including those lymph nodes and seminal vesicles, etc, will be sliced and analyzed under the microscopy by the pathologist that will inform on the findings. Hopefully they find no extra capsular extensions which would lead the outcome of surgery to the highest points. Unfortunately, HT will also prejudice a complete answer on the outcomes because it will mask the PSA, making it impossible of providing proper result and indication on remission. Your father in law will have to wait til the end of the effect of HT to get that ultimate answer. Remission status.

Best wishes and luck.

VGama 

Pathfinder

Thanks for your swift reply. 

Thanks for your swift reply. 

Yes, so I'm somewhat unsure why the initial hospital suggested 3 months HT prior to surgery. Is this way off standard procedure in the west? Is there any good reason why they would have suggested this course of treatment before surgery? I did recall your comments previously regarding this.

At the moment we're yet to get the details about the actual condition. Of course we need to wait for the pathology report, and that will take a while. As you said, the HT will need to wear off for an accurate PSA result, and we're not sure how long he should suspend it for. We'll ask the surgeon as soon as we have a chance.

Appreciate your input.

Max Former Hodgkins Stage 3

Stable

I'm glad his surgery went well and is now over, Pathfinder.

The meeting with a surgeon following a surgery is ordinarily brief even in the US, because the doctor is usually on his way to prep for his next proceedure. My RP surgeon has "surgery day" twice a month or more often, in which he is in the O.R. basically all day long.

As Vasco explained, knowing the results of the surgery is essentially a case of getting the Pathologist's Report and the Surgical Summary. These are of course DIFFERENT reports.  Language issues permitting, get PAPER COPIES of both of these, even if they have to be in Chinese. If you do not read Chinese yourself, you can have them translated later.  They will probably not be available for a few days, but if you don't get them soon, they will be much harder to track down later.

As Vasco also noted, a surgeon cannot ordinarily "see" cancer, unless the tumor is sizable or there is overt tissue differentiation.  But only the pathologist's analysis gives definitive information.  While there are positives and negatives for surgery vs. radiation, one real advantage of surgery is that after the gland is on the lab table and under a microscope, the doctors can know EXACTLY what they were dealing with, At that point, imaging is irrelevant.

He will wear a cath about a week for the uretheral reattachment to heal.

Following surgical removal, if all cancer was removed, PSA drops to "undetectable" within a few weeks.  AS Vasco in addition noted, though, the HT in his case will mean that 0 PSA readings could be partially the result of the HT. Therefore concluding that undetectable PSA results are not HT-related will not be certain until the effects of the HT has cleared his body.

Good luck and negative reports to the both of you,

 

max

Will Doran

Encouraging news

Pathfinder,

Glad your father-in-law's surgery is completed.  I had an adhesion (prostate to bladder), when they did my surgery.  However, it wasn't from the HT.  I never had HT until  post surgery.  My adhesion was a birth defect.  It did slow down the robotic assisted surgery quite a bit, plus some other complications from a double abdominal hernia repair, and extreme leg muscle development from road cycling..  The surgery was supposed to take 2 1/2 hours and ended up taking 5 1/2 hours.  I also had no metastases in seminal vesicles but did have a small spot in one lymph node.  Thus I was treated as  Stage 4.  I am , as of this past week a three year survivor, from the time of diagnosis. At my last appointment with my surgeon/urologist he is talking 10 years from now. I will see him in four weeks for my next checkup and will know more at that time.    I would suspect your Father-in-Law will have radiation after some recovery time, as a "clean up".  That's what they did with me, and it worked out well, so far.    So keep the faith.  The wait for all the reports seems to take forever, I know.  But hang in there.

As Max & Vasco said, The HT will keep the PSA at "0".  the complete resulte won't be know until the Ht wears off.  I had two years of HT, post surgery, and that has been finished for 6 months at this point.  At my last check up I was still a PSA of <0.010.  My next checkup in a months time will tell us even more.  Your F-i-L's PSA should go down quickly, post surgery.  Mine went from pre surgery  69  down to .6 in two months before I started HT and Radiation.  Then went to "0" and has stayed there for three years.  It's amazing what they accomplish with us.

Know that you all are in my thoughs and prayers.

Peace and God Bless

Will

Pathfinder

Thank you Will for sharing

Thank you Will for sharing your story and those encouraging words! The pathology report does indeed seem to take its time. That the seminal vesicles and lymph nodes appeared fine is the most encouraging news we got from the surgeon - at least we know the checkup (despite the lesser technology) was right about no bone metastases, it's just a case now of finding out if the cancer was indeed contained within the gland.

I just want to share a story with you all for future googlers and people with this condition: My father in law shared a room with a 72 year old man with PC who had just completed open surgery to remove the prostate.

10 years earlier this man had a PSA of 5, and subsequently ignored it for a decade. The PSA rose steadily over the ten years, until eventually they went to see someone. He had a PSA of 54 and was biopsied as a Gleason 9. 

When he got his post surgery pathology report back, they found that the cancer had never left the gland, never affected the lymph nodes or bones, and he's perfectly happy and well. 

It was quite an amazing story that shows there are certainly no guarantees with PC or any cancer - although I certainly would never recommend anyone ignoring a high PSA for a decade!

Thanks again for all your patience and help.

Pathfinder

When to resume HT after surgery?

I'm looking for advice regarding when HT should be resumed post surgery? I've searched the internet but can't find much info except that HT post surgery can prolong life expectancy.

Currently my Father in Law has suspended the HT since just prior to surgery until now (so about 4 days). I found this article regarding the pros and cons of NAD in PC treatment, but there's not much about when it should be continued post surgery (if at all?)

http://emedicine.medscape.com/article/455994-overview

Any ideas about this would be much appreciated, thanks!

Old Salt

Patience

Let's wait for the pathology report. If it shows that cancer was very close to the edge of the prostate, the chance of cells having escaped the prostate is greater. In that scenario, hormone treatment might be considered.

I would also want to see a PSA post surgery before making such a decision.

Pathfinder

Old Salt said:

Patience

Let's wait for the pathology report. If it shows that cancer was very close to the edge of the prostate, the chance of cells having escaped the prostate is greater. In that scenario, hormone treatment might be considered.

I would also want to see a PSA post surgery before making such a decision.

Old Salt, but he was on HT

Old Salt, but he was on HT prior to surgery for almost 2 months - will that affect the pathology report? Studies show HT prior to RP can affect the pahtology report. He's only been off of HT four days or therabouts. 

How long will it be before we can get an accurate pathology report or PSA? Some literature suggests to continue HT directly after surgery. We're not sure how long is safe to wait.

Thanks for your help!

Pathfinder

Pathologic report: Gleason 4

Pathologic report: Gleason 4+4=8，Neural invasion, invasion to the capsule, but no break through; no seminal vesicle invasion.
Immunohistochemistry Results: 
Tumor cells PSA (+), P504S (+), PSMA (+), PSAP (+), P501S (+), AR (+++), CK20 (-)., Ki67 (+ 1%) 
Basal cell p63 (-), 34bE12 (-), CK5 / 6 (-).

The pathology report is in. Apparently there is some controversy about when or whether or commence HT after surgery. Can you please give us your advice regarding this?

The details and pathology report are as follows:

Pathologic report: Gleason 4+4=8，Neural invasion, invasion to the capsule, but no break through; no seminal vesicle invasion.
Immunohistochemistry Results: 
Tumor cells PSA (+), P504S (+), PSMA (+), PSAP (+), P501S (+), AR (+++), CK20 (-)., Ki67 (+ 1%) 
Basal cell p63 (-), 34bE12 (-), CK5 / 6 (-).

Prior to Surgery, was given hormonal therapy for 1.5 months, doc said there's adhesions during surgery due to hormone therapy.  Also said pathologic report might not be accurate coz of HT before surgery.

Now 8 days after surgery, doc suggests go back on HT for at least 9 months.

Thank you for your help!

VascodaGama

Neural invasion

I wonder if the details you posted above is the total information provided in the pathologist's report. Do you have a copy?

My opinion is that the neural invasion finding is the worse in the report. Cancer spreads out via this route which could lead his surgeon to think that there are extra capsular extensions, therefore recommending  continued HT. Gleason score 8 (4+4) has been confirmed. This is an aggressive type of cancerous cells, but they indicate it to be positive to AR (+++), PSA (+) and PSMA (+), which makes them prune to an attack with hormonal weaponry, and control via PSA tests. Surely these missiles wouldn't kill the bandit but it would knock it down to the canvas. The indication on the PSMA (+) also provides possibilities for "guided" radiation missiles with a PSMA isotope (newer techniques in the fight against PCa).

Your comment on "...no break through..." may refer to negative margins. This is a particular in RP pathology when the outer skin of the gland retreats due to cutting. There is no information on the Lymph nodes which is strange because they dissected some, as indicated in your previous post. This LN data is very important and you should check with your family in China to inquire on the results.

For the moment your father in law needs to recover. When recurrence becomes apparent then he can pursue a salvage therapy with intent at cure, instead of a palliative treatment. That can be done once he ends the period on HT and gets a clean PSA result.

Best wishes for complete recovery.

VG

 

Pathfinder

Hi VGama!

Hi VGama!

Apologies, forgot LN! Lymph nodes no infection, all clean. Seminal vesicles no infection. 

They specified the overall result as being good. They said that the cancer was contained within the gland. The way they described it was that it reached the outer layer (as if talking about the skin of an orange) but did not break through. Considering this, we're very confused about neural invasion. How serious is this and how should we approach treating it? Is it more or less serious than infection of the seminal vesicles etc?

Since they stated there was no break through and no extra capsular extensions, how is it the neural invasion can still occur?

Regarding HT, the doctor didn't actually recommend it. We brought the matter to him first. He told us that HT post surgery is controversial and the NCCN don't recommend it post RP, however it was our choice. After some discussion he said due to the Gleason 8 and that he was on HT prior to surgery, it is ok to continue. But before we raised this I'm not sure they were going to suggest HT at all. So there's some confusion here.

Thank you for all of your help. 

VascodaGama

Missing information for better analysis

I agree with Old Salt's opinion. I think his doctor is not totally confident that the cancer was in fact contained so that he lean through ward prevention, recommending to continue HT. The initial diagnosis data and the findings from surgery may have lead him to believe in HT, in spite of telling you that "... the cancer was contained within the gland...".

HT after RP would not harm the outcome of surgery, it is palliative and could be started at any occasion without loosing its benefits. Radiation also can be done at any time (after RP recovery) but one should consider the possibility of an eminent spread to areas difficult to be treated later with RT, which information may be at the hands of the doctor, suggesting that such also do not exist.
Unfortunately you never shared the whole information  with us [image studies, prostate size, volume of cancer found within the gland, existing typologies other than cancer (calculi, BPH, etc), number of dissected lymph nodes, etc] found so that we cannot over opinion on the decisions (yours or of the doctor) to help in your thinking.

Overall the doctor you are referring to (maybe his surgeon urologist) seems more reliable than the previous one so that I would recommend you to trust his suggestions and follow the recommendations till apparent recurrence is set in, if ever.

It is a fact that, if surgery has solved the problem in getting rid of the cancer totally then additional treatment is not necessary. Instead of benefits the patient would suffer with added risks and side effects. But this is also the reason why doctors never mention the word "cure" to those diagnosed with PCa and then treated. The outcome is ambiguous, loads of guessing and we do not know which side to follow, but in the end that's what cancer is all about.

At the end of the adjuvant HT, if any, your next step is to wait for a surge in a clean PSA (not under the influence of HT) above a nadir to evaluate any development.

Best,

VG 

 

 

Old Salt

PSA after the surgery

To make this discussion more focussed, it would be REALLY informative to have a PSA test result now that the prostate is gone. Vasco hinted at this as well, and to make this number as informative as possible, I agree that it should be done prior to resumption of HT.

Old Salt

Difficult decision to make

I speculate that the Chinese doctor who recommended HT initially (prior to the surgery) did so on the basis of the high PSA (24). He may have thought that such a high level could mean that cancer had escaped the prostate. Now that we have seen the pathology report, this hypothesis appears reasonable. Cancer cells may (!) have escaped, especially since neuronal invasion was present.

I see three approaches.

1. No HT and wait until the PSA starts to rise (there are thresholds for taking action).

2. Starting HT (after recovery from the surgery) right away, with the intent of killing (currently tiny) metastases. As mentioned, the latter could have been the source of the high PSA (24).

3. Irradiating the surrounding tissue to kill any cancer cells that might have settled there (after recovery from the surgery); perhaps in combination with HT

 

No an easy decision to make, but perhaps other forum members will present their recommendation(s).

Pathfinder

Thank you for your comments.

Thank you for your comments.

To reiterate, the doctor didn't really suggest HT after surgery. It was more our raising of the question regarding potential benefits. He considered it and then accepted a course could be beneficial. As VGama said, this may be because of the neural invasion or potential for escaped cells - we can't know for sure.

It's too late to get that clean PSA unfortunately, since HT has already been administered, and we're frustrated about that too. So we will need to end the HT to get that reading.

Which highlights the question again of whether or not HT is actually beneficial currently. I've read some information that, to reduce side effects (which my father in-law experiences) a monotherapy (only pills or only an injection) rather than a combined therapy is better at reducing the effects. 

Additionally, since there is a finite period where HT can have an effect, I'm wondering whether or not we shouldn't stop for the time being and watch the PSA for changes.

Regarding the pathology report, believe me when I tell you the level of detail was almost non-existent. If I had more information I would most certainly share it with you.

Any advice about what to do with this HT business would be appreciated.

VascodaGama

We are not doctors but PCa survivours with own experience

I sincerely recommend you to inquire on the above and follow his doctor's advices.

HT drugs are palliative, cause side effects and work better on low aggressive hormone dependent type of cells. This action can be verified via testosterone and PSA tests. The PSA test should be done at two weeks post surgery (even under the effects of HT) to serve as an initial reference mark (this cannot be used to judge surgery outcomes or progression of the disease but it is helpful in checking drug's action). The test, then, should be done every two to three months during the first two years (most recommended). The testosterone can be done together with the PSA but it requires only one time per year, if he gets Zoladex (or similar). Both tests can be obtained at a local reliable laboratory.

Other recommended tests for those under hormonal therapies are a bone density test (DEXA scan not the scintigraphy bone scan) for screening bone health (HT deteriorates bone and cancer spreads to weaken bone), Heart health and the lipids should also be checked annually.

Best,

VG

Old Salt

It might be useful to know

It might be useful to know what kind of HT your Father-in-law is getting; a 3-month (?) Lupron (?) shot or something else? Whatever, let's see what his testosterone level will be (it should go way down to 'castrate level' in less than 3 months). And let's get those PSA results, every 3 months or so. Vasco has given you some more detail about the frequency of these tests.

I send my support to your Father-in-law for his recovery from the surgery. He will also have to face the side effects of the HT, but this varies quite a bit among individuals.

 

Old Salt

Agreed

I can't comment in detail (traveling), but I think that getting off HT is the best course to follow for now.

Of course, it will be awhile before the effects of the Zoladex are worn off.

Pathfinder

Hello again,

Hello again, Thank you for your recent comments. He is on Zoladex (monthly injection) at the moment and Bicultamide pills (daily). We are really considering stopping HT and waiting to see the true PSA result. We believe it was a mistake to go back onto HT post RP and that the doctor was simply following our request. He didn't explicitly suggest to resume HT, and in-fact pointed out it's use directly after RP was controversial. We would like to find out the result of the surgery, most importantly! And while on HT it isn't possible to get a true PSA figure. If the true PSA is low enough, then HT isn't even necessary. So can I just ask: - Is it dangerous to go on HT, then off, then on and off again: will this create resistance to the drug (the period of suspension of HT has only been very brief. A week for the surgery and that's it. Now resumed for about a week. - Isn't it better to stay off HT for as long as possible? Because eventually the drug will form resistance. If the PSA is low enough after the surgery, then isn't it best to stay off HT until it's actually needed? Thank you for your continued advice!