Prognosis question

Lmrunner

My husband was diagnosed with prostate cancer at age 57. He had a radical prostatectomy in September 2017 but doesn’t want to do anything further. He tells me not to worry but I still do. I was just wondering if anyone out here could help me understand how serious this is, what his prognosis might be, etc. His stats are as follows:

PT3a, pN0, pM (na)

perineural invasion - present

posterior left - positive margin

stage 3

gleason - 4+5=9

tumor = 25% of prostate

 

thanks!

Old Salt

Need post-op PSA data

The follow-up PSA test results are crucial for meaningful advice.

contento

Lm

Lm, your husband's data is almost identical to mine. I also was a stage 3 , Gleason 8 , lympho & perineural invasion and a positive margin. I also had surgery. This was in Jan 2013.

As old Salt points out you must find out your husband's  psa post surgery ( I think it was after 3 months but I don't exactly recall ). If it is below .1 ng/ml your under control at this point and you should have your husband do the psa test every 3 months.  No fasting is required so it's a simple blood test. If his psa post surgery is at or  higher than .1 ng/ml then he may need more treatment and you should definitely  encourage him to seek that out. The type of post treatment suggested if needed will depend on where the cancer is located.

Hopefully he will take the next step and get his psa checked . In my opinion his life depends on it. Please encourage him... Good Luck - contento

Lmrunner

contento said:

Lm

Lm, your husband's data is almost identical to mine. I also was a stage 3 , Gleason 8 , lympho & perineural invasion and a positive margin. I also had surgery. This was in Jan 2013.

As old Salt points out you must find out your husband's  psa post surgery ( I think it was after 3 months but I don't exactly recall ). If it is below .1 ng/ml your under control at this point and you should have your husband do the psa test every 3 months.  No fasting is required so it's a simple blood test. If his psa post surgery is at or  higher than .1 ng/ml then he may need more treatment and you should definitely  encourage him to seek that out. The type of post treatment suggested if needed will depend on where the cancer is located.

Hopefully he will take the next step and get his psa checked . In my opinion his life depends on it. Please encourage him... Good Luck - contento

Thanks

thank you for the info. So far, so good. He’s had his psa checked twice and both times, it was 0. He’s getting it checked again in March. 

contento

Lm, that's excellent news !! 

Lm, that's excellent news !!  Let's hope it just keeps going like that.

Old Salt

So far so good!

Let's hope your husband's PSA will remain undetectable for a long long time. Unfortunately (and I hate to write this), the pathology that you reported is not favorable for that to happen. If his PSA does start to rise, some sort of treatment will be recommended by the medical profession; usually salvage radiation. The latter consists of a series of radiation sessions that are usually well tolerated by the patient. If the cancer has truly escaped (metastasized), other treatments should be considered. But let's enjoy the good news for now.

 

VascodaGama

I wonder what was his decided initial treatment protocol

Lmrunner

At this moment nobody knows if the surgery has fixed the problem. Surely this is a worrisome period because we are dependent on the PSA values. Constant increases may signify recurrence and it is only at that time that doctors recommend additional action, as commented by above survivors. However, some surgeons got their "predictive tools table" (own list of thresholds based on their experiences) to judge/predict surgery failure or success. My surgeon used a PSA threshold of >0.06 ng/ml at the first PSA post op to indicate failure of the surgery. When positive margins are present and are located closed to the tumor detected in image exams or by the biopsy, some doctors may recommend adjuvant radiation earlier at the pelvis, disregarding the PSA marker.
I wonder if his doctor has suggested already adjuvant radiation due to the pathologist report, but your husband has refused which made you to worry. I also wonder if the original treatment protocol was for a combination therapy of surgery plus radiation which decision your husband is now retreating.

In my lay opinion, the worse in the status you describe above are the grade of the cancer "Gleason 9" and the "positive margin". Grade 5 is the highest for aggressivity and these type of cells (poorly differentiated) are much linked to progressive cases of PCa. The location of the "posterior left positive margin" is the area in contact with the colon. In surgery typically there are two places of positive margins caused during dissection of the gland. One is at the base of the prostate (close to the bladder) and the other at the apex (close to the colon). When dissecting the walnut like gland its shell's skin retreats exposing the inner tissue. This exposure is reported by pathologists as "positive margin". At other places it could mean that the cancer has perforated the shell and spread out side.
Surely you do understand that if this area of the gland had cancer then probabilities of spread would exist. You can verify the location of the cancer in the gland from retrieved data; the biopsy report, CT or MRI or PET exams, and DRE results. Do you have any of these reports?
Other relevant data which physicians use to predict recurrence are the PSA histology (before and after surgery) and symptoms. Can you provide us with such details?

The pathological stage of pT3a pN0 (pM-na means no information) is a classification done to evaluate risks, however, surgery could have cured your husband. The percentage of cancer (volume) identified by the pathologist is useful to compare against the estimated PSA produced by cancerous cells or to predict the type of cancer. 25% may indicate that his cancer forms into individual tumors, therefore ruling out micrometastases.

You comment above that his PSA is 0 but there should be a number. Can you tell us the real value? Do you have copies of the results and reports?

Best wishes for continued low levels of PSA meaning complete remission.

VGama

 

Max Former Hodgkins Stage 3

Old Salt said:

So far so good!

Let's hope your husband's PSA will remain undetectable for a long long time. Unfortunately (and I hate to write this), the pathology that you reported is not favorable for that to happen. If his PSA does start to rise, some sort of treatment will be recommended by the medical profession; usually salvage radiation. The latter consists of a series of radiation sessions that are usually well tolerated by the patient. If the cancer has truly escaped (metastasized), other treatments should be considered. But let's enjoy the good news for now.

 

Agree

Lmrunner,

I totally agree with Old Salt:  A man with positive margins, very high Gleason, and perineural involvement should have begun secondary radiation (IMRT, IGRT) shortly after healing from the surgery.  It is unbelievable to me that the surgeon would not have insisted on this.  

But like everyone, let's hope for the best,

max

Lmrunner

VascodaGama said:

I wonder what was his decided initial treatment protocol

Lmrunner

At this moment nobody knows if the surgery has fixed the problem. Surely this is a worrisome period because we are dependent on the PSA values. Constant increases may signify recurrence and it is only at that time that doctors recommend additional action, as commented by above survivors. However, some surgeons got their "predictive tools table" (own list of thresholds based on their experiences) to judge/predict surgery failure or success. My surgeon used a PSA threshold of >0.06 ng/ml at the first PSA post op to indicate failure of the surgery. When positive margins are present and are located closed to the tumor detected in image exams or by the biopsy, some doctors may recommend adjuvant radiation earlier at the pelvis, disregarding the PSA marker.
I wonder if his doctor has suggested already adjuvant radiation due to the pathologist report, but your husband has refused which made you to worry. I also wonder if the original treatment protocol was for a combination therapy of surgery plus radiation which decision your husband is now retreating.

In my lay opinion, the worse in the status you describe above are the grade of the cancer "Gleason 9" and the "positive margin". Grade 5 is the highest for aggressivity and these type of cells (poorly differentiated) are much linked to progressive cases of PCa. The location of the "posterior left positive margin" is the area in contact with the colon. In surgery typically there are two places of positive margins caused during dissection of the gland. One is at the base of the prostate (close to the bladder) and the other at the apex (close to the colon). When dissecting the walnut like gland its shell's skin retreats exposing the inner tissue. This exposure is reported by pathologists as "positive margin". At other places it could mean that the cancer has perforated the shell and spread out side.
Surely you do understand that if this area of the gland had cancer then probabilities of spread would exist. You can verify the location of the cancer in the gland from retrieved data; the biopsy report, CT or MRI or PET exams, and DRE results. Do you have any of these reports?
Other relevant data which physicians use to predict recurrence are the PSA histology (before and after surgery) and symptoms. Can you provide us with such details?

The pathological stage of pT3a pN0 (pM-na means no information) is a classification done to evaluate risks, however, surgery could have cured your husband. The percentage of cancer (volume) identified by the pathologist is useful to compare against the estimated PSA produced by cancerous cells or to predict the type of cancer. 25% may indicate that his cancer forms into individual tumors, therefore ruling out micrometastases.

You comment above that his PSA is 0 but there should be a number. Can you tell us the real value? Do you have copies of the results and reports?

Best wishes for continued low levels of PSA meaning complete remission.

VGama

 

VGama  Thank you for your comments  here’s the info I could find  

His psa results were shown as less than .01

here is a copy of his biopsy results

                                           CANCER CASE SUMMARY (PROSTATE GLAND)

 

  Procedure:

    -- Radical prostatectomy

  Prostate size:

    -- Weight: 45.7 g

    -- Size: 5.0 x 3.2 x 1.2 cm.

  Lymph node sampling:

    -- Pelvic lymph node dissection

  Histologic type:

    -- Adenocarcinoma (acinar, not otherwise specified)

  Histologic grade(Gleason pattern):

  Primary pattern

    - Grade 4

  Secondary pattern

    - Grade 5

  Total Gleason score: 9

  Grade group:5

  Tumor quantitation:

   -- Proportion (percentage) of prostate involved by tumor: approximately 25%

   -- Tumor size: 16 mm in greatest dimension

  Extraprostatic extension:

   -- Present, focal

  Urinary bladder neck involvement:

   -- Not identified

  Seminal vesicle invasion:

   -- Not identified

  Margins:

   -- Margin involved by invasive carcinoma

      -- Limited (<3 mm), focal

  Location of positive margin:

    -- Posterior (left)

  Treatment effect on carcinoma:

    -- Not identified

  Lymph?vascular invasion:

    -- Not identified

  Perineural invasion:

    -- Present

  Regional lymph nodes:

    -- Number of lymph nodes submitted: 6 (see part A and

       -- Number of lymph nodes involvement:0

       -- Number of lymph nodes examined:6

  Pathologic staging: pT3a; pN0; pM(not applicable)

 

 

VascodaGama

risks of future recurrence exist

Lmrunner,

Your description above is the pathologist's report on dissected gland as a specimen. The byopsy data was retrieved before surgery at the time of diagnosis (before September 2017). You may get a copy of that report (with the number of needles/cores taken and its location) from the office of his urologist. They also have the results of image studies (bone scan, CT, MRI, etc).

In any case, your shared info above reports the finding of "Extraprostatic extension: Present" and , "Margin involved by invasive carcinoma", indicating that his case is not contained. Such data turns your husband's case more serious and at higher risk for experiencing recurrence in the future. Most probably his doctor has already commented on the need of additional radiation.

The PSA=,0.01 ng/ml at 4 months since surgery indicates remission. This status can last many months or even years. Nobody can tell for sure that recurrence will occur. However, the risk is there and the majority of the guys in similar cases experience recurrence in the end.

Doctors usually recommend to young patients in similar situation to get treated the soonest. Being young assures earlier recovery, but radiation works the same if done latter. The field of attack would not alter and the cancer does not become more aggressive. Surely allowing the bandit to spread further is not good. My opinion is that your husband can do radiation once his PSA validates recurrence (if metastases have not yet been confirmed in image studies).

In any case, there is missing data required to judge your case. Survivors can help you better if you provide copies of the reports, PSA histology and symptoms, before and during diagnosis.

Best wishes,

VG

contento

Lm

Lm, Vasco's analysis is spot on. Your doctors will most likely use your psa values as their marker going forward ( I'm making the assumption that his scans were ok ).

It seems different institutions use different psa values as their trigger points. Mine used less than .1 ng/ml to determine surgery success and greater than .2 ng/ml to determine reoccurance.

as Max pointed out some institutions will recommend adjuvant radiation to those patients who had successful surgery ( less than .1 ng/ml ) but was determined pathologically to be at a very high risk for reoccurance. Other institutions however will wait to see if in fact that patient's psa will rise over time beyond their specific thershold. Then will recommend a treatment protocol. Since your husband's data is very similar to mine I know that the risk of reoccurance is very high but not definite. Like you and most all of us we worry about our survival statistics . After my surgery in early 2013 my pathology was a lot worse than the scans and biopsy indicated. I had asked my doctor, which I was scared to death to ask,  to run the numbers on the survival probabilities givin my situation. He said the 15 year survival rate ( prostate cancer specific ) was better than 90 %.I was happy with that number and I definitely didn't want to ask anything further.

At this point my best advice is to stay on top of your psa. I would think you would want to check this every 3 months faithfully.

Good Luck --  contento

Old Salt

Confusion

Lmrunner husband's PSA was reported as less than 0.01 (2/12). In other words, undetectable with the assay used. This invalidates some of what Vasco wrote (2/13). But much of what has been written appears to be academic anyway because Lmrunner posted (2/10) that husband doesn't want additional treatment...

Lmrunner

Further treatment

My husband would rather take his chances then go thru radiation. So far, he hasn’t fully recovered from the surgery. He still has to wear depends due to leakage and is having other issues as well. He’s a top age group athlete in triathlons and running and would like this part of his life to continue and is afraid radiation would cause side effects (colostomy bag, etc) that would prevent this. So he’s opting for quality of life over quantity. I’m just not sure how many years he has left, given all the statistics. He’s thinking 10-15. 

Max Former Hodgkins Stage 3

Lmrunner said:

Further treatment

My husband would rather take his chances then go thru radiation. So far, he hasn’t fully recovered from the surgery. He still has to wear depends due to leakage and is having other issues as well. He’s a top age group athlete in triathlons and running and would like this part of his life to continue and is afraid radiation would cause side effects (colostomy bag, etc) that would prevent this. So he’s opting for quality of life over quantity. I’m just not sure how many years he has left, given all the statistics. He’s thinking 10-15. 

Not ordinarily

Lm,

A few comments on your last post.  First, radiation always waits for a prior surgery to heal, it is the norm.

Second, IGRT (the kind of radiation he would/will receive) virtually never causes sever colon or intestinal damage.  And I have never heard of it being bad enough to necessitate an ostomy bag.  Also, it seldom worsens incontinence significantly.

Finally, "statistics" never determine a patient's lifespan.  Several years ago, the survival rate for men with Stage 4 metastatic, aggressive PCa to bone at initial diagnosis was over 5 years, and their diagnosis was wayy worse than probably 95% of newly diagnosed PCa patients. And survival rates are increasing annually.  Most likely, your husband can live decades yet with high quality of life, even if he has radiation.   Hope for the best, but my approach is always to be more aggressive toward potential cure.

I would speak to his surgeon and a radiation oncologist for a consult if it were me.  NOT assuming you would do radiation, but to learn of the specifics in his case and what the liklihood of side effects actually is,

max

J Doe

Suggestion: Continue research on ALL possible treatments

I'm new to this forum, but in our battle (Stage 4, bone metastases only, recently castration resistant, but healthy, active, 60-year old diagnosed 2 years), we've found that for otherwise healthy individuals who demand to maintain their quality of life (and don't be shy about demanding it!) you need to do your own research and be very forthcoming about your expectations to your oncologist.  My guy was basically handed a grave prognosis, but has had no disease progression in the two years at all, so the one-size-fits-all standard of care wasn't acceptable (chemical castration and wait a few years to die).  Explore proton therapy, and radiation is not as debilitating as your initial indications.  It is well-targeted.  The standard-of-care treatment that would be next if he has a recurrence is far more life-altering than even a colostomy bag would be.  Best wishes to you!  The best gift a patient can have is a reasonable, but assertive advocate.