Path report & Robotic Surgery - help please?

It is my understanding that if the prostate cancer cells have left the gland, then you should not have the robotic surgery, most common side effects (incontinence, erectile dysfunction, urethra shortening).  I had an RP in March of this year.  My Gleason was 4+3=7.  I was told the cancer was local to the prostate gland.  The post op pathology showed free of cancer cells.  If you like just look my name up lighterwood67 and you can read my pathology and the actual surgical procedure.  I am not telling you what to do.  I am telling you that I elected to have the gland removed because I was told that the cancer was contained in the prostate.  So do your homework.  Ask a lot of questions.  Good luck on your journey.

Old Salt said:

Is surgery really the best choice?

As lighterwood already wrote, I sure hope you study the alternatives. The medical info that you provided is too limited to provide clear alternatives. Please tell us more (see Vasco's post).

Where are you located? I am asking because a seven-sample biopsy is not Standard of Care in the USA these days. 

More in general, robotic prostate removal surgery is possible for a 70-year old, assuming you are in reasonaly good shape. If you decide to go that route, make sure the surgeon has a lot of experience (a few hundred surgeries).

Leo,

At 70 and very overweight, you are pushing the limit on RP being a best first choice. Also, as the others have said, there is a good possibility that the disease has exited the gland into adjacent tissue.  RP is not a good firsrt choice in cases of likely or certain escape.

If I were you I would investigate IMRT radiation or Cyberknife.  I say this as a guy who chose DaVinci RP and had a great outcome. But my situation was very different from your's .

Your biopsy report says that perineural exit is not seen, but Summary #5 says that perineural invasion IS seen. This means that the disease has entered into the sheathing around the nerves inside the gland, but so far as best they can tell it has not exited the gland.  This is somewhat of an educated guess on their part, since disease that small is not detectable on scans.

If it were me, I'd get to a radiation oncologist, first opportunity.

max

LeoJ said:

Feedback and thanks for same

I am in Australia and the difference in time zones plus the need I have to digest a lot of information fast (recent diagnosis) mean that there is some delay in reply.

So far I have not had any other professionals involved apart from the GP, urologist (incl the biopsies) and from the radiologists (MRAs and CT/PET scans). No other recommendations have been proferred outside of surgery.  Regarding the previous colorectal surgery, the lab report indicated that the cancer was contained (and removed).  However the CT/PETs continue to show other activity, specifically to the peritoneum (if cancer, incurable).  The surgeon (colorectal) believes that the activity is more possibly resulting from the previous surgical intervention. No link has been drawn between the colorectal cancer (successfully removed) and the recent found prostate cancer (which did not show on ny of the MRI, CT and CT/PET scans done in connction with the partial colectomy.  A CT/PET of the prostate did show some 'activity', but likely again that could just be the 'shadows' due to healing.

Returning to the prostate cancer, I am not aware of any further test that could help to prove 'localised', but doubtless a scheduled consultation with the surgeon will educate me on that and other isseus.  What am I missing?  Back shortly and many thanks for the comments so far.

Leo,

As you obviously know, cases with interaction from other cancers complicates both diagnosis and treatment a lot. A great shortcomng with PCa is that usually available imaging (all kinds) simply will never tell a doctor ABSOLUTELY whether PCa has wandered off (out of the gland) or not.  Bone scans, PETs, MRIs can detect and show severe or advanced metastasis, but not micrometastasis -- cases with only minute amounts of escape.  But doctors use all the current tools that they have, which is necessary, obviously.  Correct diagnosis im imperative.  Treating the wrong disease will worsen things, not improve them. 

Your urologist was totally correct about one thing:  Only surgery can tell a doctor with certitude what is wrong with the suspicious node(s).  Men in reasonable heath routinely get prostectomies at 70 years of age or older, but the reason for choosing surgery ordinarily needs to be compelling.  Your situation may indeed be compelling to choose surgery. 

You remind me of me in one regard, although I have never had intestinal cancer:  You've been through so much that you know beforehand how tough major surgery is, and can deal with the aftermath.  I've had over 20 surgeries myself, and although many of these were minor proceedures, like tube insertions, excise biopsies, cathiport installations, about eight of them were serious, involved proceedures: R.P, gall bladder removal, installation of prosthesis, corrrective hernia repair of previous incisions, etc.   Eventually going under the knife just becomes a routine, sort of like checking into a motel on vacation.  I go to the cancer center the way women go to the grocery to grab a bag of onions: while thinking of other matters. 

After having battled advanced lymphoma, when my wife and I went to the urologist's office to get my prostate biopsy results, the doctor came in all serious and started with explaining options.  It was early in the morning and we both expected the results.  I unintentionally yawned in the urologist's face, and said,  "Yea yea, I understand. Thank you. Schedule me for  a consult with a surgeon and a radiation doc. But for now, I need to get home and go back to bed."  Then, a suspicious nodule inside a lung, that required CTs for monitoring over a two-year protocol. 

When the doctors talk I just here the TV characters from Sienfeld saying "yadda yadda yadda."  It becomes a blur eventually.  But we focus as best we can and make informed decisions.

I hope continuing investigation brings some clarity to you and your medical team, and I hope you continue to share what is learned.

max

LeoJ said:

Urgency and reply to max

Hi max,

The Urologist sees radical surgery as the only real choice.  It will remove the main burden of potential leaks of canceroius cells to other tissue and if lucky, result in a cure.  Also, taking other alternatives creates complications that would remove the surgery option in my case.  Specifically, that radiation would 'weld' tissues together.  I suppose I already have a lot of adhesions from the previous bowel cancer operation, an abdominal exploratory (prior to the discovery of the prostate cancer) and recent biopsies.  The sub-total colectomy was not planned. 

The problem is that the first step is always major and there is no going back, the course is set.  

Leo,

You are well informed. Your's is one of those special cases.  After whatever further testing they are doing, I would order the surgery as soon as possible if I were you.  Please continue to share, as it is informative to everyone here. Good luck. I chose surgery for similiar reasons, because if R.T. is used first, it creates a mountain of scar tissue, and really renders later surgery almost impossible.  Some here write that surgery post-rads is doable, but most surgeons in fact WILL NOT do it, and it is problematic. 

My own surgeon is one of the leading post-radiation R.P guys in the nation, and he has told me this himself.

max

LeoJ said:

Going ahead

Hi Max,

Thank you for your continued interest and support. 

I am intending to have the surgery ASAP and accept that it can be more extensive than the prostate.  Did your surgery involve lymph nodes?

Will be keeping up with the forum for mutual benefit

I am 67.  I can't speak to the radiology side of your treatmnet as I have had none.  I made the decision to have a RP, based on the medical advice that even with a Gleason of 4+3=7, the cancer appeared to be contained.  My prostate was removed; 8 pelvic lymph nodes; and a bladder reconstruction.  My post op pathology report was clean.  Side effects:  5 months post op:  incontinence (1 shield during the day, very little leakage), none at night); erectile dysfunction (probably around 75 % recovered); urethra shortening.  As you are aware, surgery is permanent.  First PSA at 4 months post-op was undetectable.  Wish you all the luck in the world on your journey.  

Leo,

Your comment on the LN surprised me. I wonder what is the treatment protocol and the reason for your choice. When lymph nodes are involved doctors try dissecting a higher number at the iliac which can be reached in open surgeries. Robot types usually dissect the close ones. However, some doctors try dissecting deeper LN through the robot holes in the belly (some cutting is required) by hand.

In fact, in common cases when LN are suspicious of involvement, good surgeons start the operation by dissecting some firstly, then stop and wait for the analysis of the LN done by the pathologist at the hospital straight (a matter of 15 minutes) and then resume the operation if these were found negative. In case of a positive finding , then they stop the operation at the mid, stitching the patient and recommending him to radiotherapy. The meaning is that surgery would not resolve the problem alone.

If you are in doubt of your choice, you can still speak with the surgeon before the operation to clarify the matter. You can even request for a postponement. In any case, as Hopeful above comments, you can radiate those deep affected LN latter (after full recovery from RP) as means of precaution or if recurrence is verified. Such would add more risks and side effects but RT would be an option again.

You need to be relaxed for the D day. If worried just try calling his office and inquire by phone. Please remmember that we all have had similar experiences before D day and we all survived. That is the motto of being a PCa survivor.

Best wishes for an eventless operation.

VGama