New here, upgraded following RP to pT3a Nx R1 Gleeson 3+4=7 Tertiary pattern 5

Hi Bowie,

Welcome to the board.

I am sorry to say but I concur with his urologist's comments. Your husband is experiencing biochemical failure (constant increase of the PSA) which relate to recurrence. The good thing is that his case is treatable.

The pathologist report on the specimen (the whole gland) identified three issues which makes the case riskier and in need of additional treatment. The cribriform type in acinar PCa are typical in metastatic cancer and the identified extraprostatic extensions reinforce the comment on radiotherapy. The Gleason grade 5, though small percentage, is the highest and prone to spreading.

His doctor wants to wait for a PSA of 0.2 ng/ml as a formal way recommended in the NCCN guidelines. PSA =0.2 after RP signifies recurrence and intervention is best if done before a PSA of 0.4. Meanwhile, additional image studies are required to verify the extent of the spreading.

Nx in the pathological stage signifies that lymph nodes were not presented for analysis. This is a rare case in prostatectomy as usual surgeons dissect a few number of LN together with the gland. Another missing item is Mx (far metastases) which the doctor will be checking via the bone scan. In your shoes, instead of a CT, I would request a MRI 3.0T. The CT is not reliable in small tumors, which may be your husband's case. PSMA PET scan is also very reliable when the PSA is higher close to 0.7 ng/ml.

Typically, pT3a cases are lead to salvage radiotherapy (SRT) that can be done in combination with hormonal treatment (ADT) but the cribriform type cases some doctors recommend a combination of chemotherapy plus radiotherapy. You need to get second opinions on the matter.

You need to move but do it coordinately. You should consult a radiotherapist and probably a medical oncologist expert in prostate cancer. Uro-oncologists are good too but get second opinions from other doctors (with all the data in hand including image studies) before deciding on your next step.

Best wishes and luck in this journey. VGama

Hi again,

Your doctor's comments seem reasonable. He is saying; "wait three months, get the image studies and then consult a radiologist to make a final decision on the SRT protocol. In fact he is following the standards of AUA which recommends a sort of sequential therapy (salvage after salvage when needed).

I do not know how experienced this doctor is in treating PCa but in my opinion he has failed in not dissecting a number of lymph nodes during surgery for analysis by the pathologist. Probably he trusted the results of the initial MRI reporting T2 N0, as described in your above post, but now comments that those image studies are not reliable to identify small tumors.

However, his participation in the continuing treatments is minimal. Radiation treatments are done by radiologists and further on you will need a medical oncologist.

Regarding the salvage treatment protocol, it starts with (ADT) two weeks of antiandroges followed by a LHRH agonist shot, and two months later your husband will start the daily radiation sections (except on Sundays) that will be prolonged to 8 to 10 weeks. Each daily section takes about one hour so that choosing a local radiation clinic of easy access may be the best.

The Radiation planning should include in its field a series of lymph nodes apart from the prostate bed. You should inquire about the details planned by the radiotherapist. He can save the area close to the bladder sphincter (avoiding incontinence issues). ED will not be affected further but radiation will create scars at the colon. It takes two to three months to recuperate from the RT side effects. Those caused by ADT will last about three to four months long after the end of the drugs effectiveness.

In my opinion, waiting three to six months to start RT is reasonable. The present status will not alter during this period so that you can you can use this time in preparedness. It will be wise to have a full panel blood tests that should include, apart from the PSA, a testosterone test to check future ADT issues. A colonoscopy to check for ulcerative colitis should be done before RT. It will help in the planning of the areas of attack. DEXA scan helps in checking for any osteoporosis/osteopenia typically affected by prolonged hormonal treatment.

Best wishes,

VGama

Hi,

Sounds like you have a plan to start your treatment path. Sometimes you have to let the cancer grow so you can find it to radiate, hopefully the scans will find areas to treat. If it was me I would be researching the various ADT drugs and their side effects so when that time comes you are prepared to decide with your doctor(s) which drug will work best with the least side effects. Do you know what type of RT your doctor is think of? Might want to look into those also, I have heard Cyberknife and Proton radiation are both very good. I have included some links you might find interesting.

https://training.seer.cancer.gov/treatment/radiation/types.html

https://www.cancer.org/cancer/prostate-cancer/treating/hormone-therapy.html

Dave 3+4

I am sorry that you need to be the one to study your husband's case, but you are doing a great job. It is very common to feel depressed, anxious or angry when faced with prostate cancer. Many though will 'settle in' once they become more knowledgeable. I hope that that will be true for you as well.

With respect to the medical details that you have provided, I agree with the others that the path forward seems reasonable. Let's hope that it will be successful.

Now, with respect to those lymph nodes, I am not a doctor by any stretch, but I have read that they provide a useful function and that removing all of them will lead to other problems. But, as Vasco already stated, many surgeons do examine a few lymph nodes during surgery and may modify their procedure based on the pathological results. However, there must be pros and cons because not all surgeons do this.

Here's a link to a paper that appears relevant:

Reconsideration on Clinical Benefit of Pelvic Lymph Node Dissection during Radical Prostatectomy for Clinically Localized Prostate Cancer - FullText - Urologia Internationalis 2019, Vol. 103, No. 2 - Karger Publishers

Hey, Bowie

I didn't read the post you deleted but it is natural to be sad and worried when our partner confronts cancer. We all go through that experience. In the end we are dealing with the unknown and just trying to fight it the best we can. Nobody is to blame.

Your husband is suffering too even if he doesn't seem to collaborate in your investigations. ED affects us men mentally a lot. You need the understanding of each other, find that way of happiness and advance in life.

We need luck too. Let's hope for a successful SRT.