My Recent Pathology Report

Max Former Hodgkins Stage 3 said:

Secondary Treatments

JMS,

Your pathology report (Item #1) indicates that the disease escaped the gland, and in addition there was PNI (Perineural invasion; cancer growing along the nerves inside the gland), and several positive margins (cancer touching the edges of the gland).

At a minimum I would expect the doctor to begin precautionary/possibly curative radiation therapy.  I would expect him to insist on this regardless of the PSA results.  If he does not propose this, I would ask him why he is not.

max

JMS58

Welcome to the board. I am sorry for the positive margins and extracapsular extensions found by the pathologist. This together with your initial genes tests indicates that you will require extra vigilance and strike any recurrence the soonest but timely. Not many reports about having possibilities on gene mutations and I think you did well in getting such tests and diagnosis.

You have been cautious and I am surprised that your doctor has not included in the surgery protocol dissecting a number of lymph nodes for analyses. It is common in open surgeries to do so for 9 to 11 nodes. This is important in cases where the prostate is “big”. Probably the team gave prime attention to the biopsy results (with only one positive core) disregarding the possibility of extra capsular extensions.
The MRI with the gadolinium contrast also does not reliably provide a clue of such “invasion”.

I wonder if you had hyperplasia. This is a condition that pathologists address when the size of the prostate is bigger than the normal. Yours with Weight 63 grams Size 3.5x4x3.5 cm can be compared to the more typical Weight 25 grams Size 4 x 2 x 3 cm. I also cannot understand their meaning for “Severity and Extent of Tumor: 3/5 (3 being 15 - 30-%)”. Three fifths is quite extensive and does not “contrast” well with the biopsy results. A voluminous cancer Gs 7 could mean a case of micrometastases.

Your pathological stage pT3a, pNX, pMX is for recurrence risks. It is hard to certainly trust that the cancer has only spread to close extraprostatic soft tissue. In any case typical recurrences after surgery are addressed with a series of radiation sections to “zip” the prostate bed. Some doctors suggest immediate salvage treatment others chose to confirm recurrency. If such becomes your future case then I would suggest you to request the RT to include the lymph nodes.

In my lay opinion, it is still earlier to draw conclusions. The following series of PSA tests will provide you the information regarding recurrences. Many guys managed long remissions periods of ten or more years. The sequential therapies (with radiation) are well documented and we know what to expect from them, the immunotherapy is still “young” undocumented but it may be a good candidate, however it is not free of risks, and at your young age I would avoid to the maximum treatments that can prejudice your quality living, unless it is absolutely necessary.

We PCa survivors suffer more from treatment side effects than from the cancer itself.

Best wishes and hopes for remission.

VGama

JMS58 said:

How bad is the Radiation Treatment?

Thanks Max

I know I will most likely be going through Radiation Therapy.
I guess I will have to research this now.
I am moving my treatment to Mass Gen Hospital so I do feel I will be in very good hands.

How many radiation sessions am I looking at?

I will do my due diligence and research my treatment options.

JM,

To some extend, Vasco answered your question for me.  There is a line of thought in salvage therapies for prostate cancer that suggests holding remaining treatments as long as is reasonable, which some studies show sometimes extends overall life expectancy for highly indolent or dormant disease.  The question is always, "How long would be too long ?"

The thinking in applying radiation now would be that all evidence available from the pathologist's analysis of the removed gland suggests that there are still prostate cancer cells in you, and radiation would likely kill them before they wander off to farther locales in your body.

If I were you, I would hash all this out with the doctors at Mass General.  I would demand to speak with a radiation oncologist, and any other experts they send your way. And get the opinion of your surgeon also; he has insights most likely as well.  A "medical oncologist" is a non-radiation guy, meaning an oncologist who treats with drugs, verses radiation. That is, a doctor who would direct any hormonal therapy or chemo, but you are undoubtedly, worse case scenario, years or even decades away from ever needing chemo.

Like Vasco, I would question the decision to not remove nodes during the surgery, although that ship has sailed at this point.

Why the doc removed part of the erectile nerve bundle verses all of it is another question I would have him answer.

I have no idea how much radiation you will be recommended.  For guys with the gland still in place, it is usually 38 treatments, at around 76 Gr ("Gray," the dose of radiation delivered).   For salvage therapy (also called "Second-line therapy"), I am unfamiliar, but a lot of guys here have had salvage radiation treatment.

Basically, you have a lot of research to do, and need to speak to an assortment of experts.

I hope their assessments are all hopeful, and that they feel you can do with less treatment, verses more,

max

Rakendra said:

Side effects

We PCa survivors suffer more from treatment side effects than from the cancer itself.

   The wonderful thing about these boards is that one can get very different opinions and the chance to express them.  The above statement is a fine example.  There are difinitely two sides to this.  As for me, I have had NO problems from my very advanced cancer at all.  Treatment was an absolute disaster, not only from a physical standpoint, but also treatment created severe emotional issues as well.  It is not one size fits all.  Very different results can come from similar cases and similar treatments.  I guess the real answer is that no one knows for sure what is going to go down.  It is just wait, see, and pray.  love, SwamIi Rakendra

...with 2 extracapsular extentions. (they pulled and checked a bunch of lymph nodes and a chunk of my colon as well - all were negative) 1 seminal duct was involved and he had to take 'some' of my nerves. 35 gram tumor...also found out I am allergic to the 'Steri-Strip' surgical adhesive, got a dozen quarter-sized blisters around the incisions. Those came off when he pulled the bandages. That was kind-of gross and painful. 2 weeks after my Dec 2012 RARP my PSA was 0.2ng/dl so the doc started me on ADT with Firmagon (as there is no Testosterone flare with that chem) 3 months later, still on Firmagon, they checked to see if I was continent. Since I was continent they started me on my 80 Gy of Cyberknife EBRT. 2 months, every weekday. They also switched my chem to Lupron, then to Eligard. At this time I have passed the dotted line at the end of ADT chemo and am 2 years out from my last radiation treatment. I anticipate a return to 'normal' sometime in the next year.

I am informed that my treatment is right on the current reccommendations for a healthy 64 year old such as myself. The treatment side effects have been annoying, but they are nothing compared to a slow, painful death from metasticized prostate cancer. I must admit that I live in a wealthy area so I have access to the very best treatments and doctors you can get. I am also a 'health nut' and an athelete so I started out with a major advantage. I only took 2 weeks off of my fitness program for the surgery, after that I was back at it so I remain in a statistically advantaged cohort. The doc tells me there is a 20 - 30 % chance of the adenocarcinoma returning, that means there is a 70 - 80 % chance it will not. I will find out as we go along now.

JMS58

I am sorry if my above “statement” was not proper or lead anyone toward a wrong conclusion as commented by Old salt. By experience survivors who live long years with the bandit live also with the side effects from treatments, which in the majority prejudice to a certain extent the normal quality of living. The cancer is symptomless but a death caused by prostate cancer seems to be painful.

Regarding the analysing of nerve bundle while in operation, questioned by you, this is not a common practice, however, in open PCa surgeries, dissecting firstly a few number of close lymph nodes to get them analysed at the facility’s laboratory, fast, it is done before dissecting anything else with the intent in verifying if surgery has been the proper choice. If these were "contaminated" with cancer then doctors would stop the operation and stitch up the patient. He would be recommended for radiation therapy, instead.

Using the nerve bundles with the same principle to decide on a surgery with or without nerve-spare technique seems to be a good idea but I wonder how they decide in a “contaminated percentage” without dissecting them all. I think the choice of 50% was guessing work. If the surgery managed to get rid of the cancer totally then the choice was good because it gives you higher and faster chances for complete erection. A future salvage treatment using radiation could undermine their good job.

I hope your next PSA indicates remission and that stays like that forever.

Best,

VG

JMS58 said:

PSA post Surgery is 0.1ng/ml any comments?

I thought this was great news as I won't need radiation and or Hormone Dep...

IS this good news or bad news?
I will be seeing my new Doctor at Mass Gen next week to discuss, but thought some input from this experienced forum would be helpful'

 

 

 

it seems to me that some form of radiation, perhaps combined with hormone therapy, is in your near future because your pathology report showed that some cancer had escaped the prostate. And your recent PSA report seems to agree with that observation.

If I am wrong, you can send me the bill.