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Need advise - Gleason score 4+4 = 8 on post operative biopsy

Neha5
Posts: 2
Joined: Aug 2017

Hi

My father was diagnosed with prostate cancer. Age : 76 years ; Physically active sportsman

The preoperative biospy report said :

Gleason score : 3+4=7 ( both lobes involved) ; 12 out of 12 cores were positive.

We went in for robotoc surgery and the final biopsy report post surgery reads:

Gleason score : 4+4 = 8 for both lobes

Perinueral invasion is seen. Extraprostatic extension is seen. Adjacent prostate shows focal local grade PIN.

Tumour consititues 55% of total volume. Semnical vesicles are clear. Margins are negative.

The doctor has advised to wait for 3 months to decide on adjuvant therapy . to do PSA count after 3 months.

Does this mean he will need radiation or hormonal treatment?

Also he is facing incontinence while changing posture after week 1 of surgery. How long is this likely to last. Please do advise.

Thanks

 

VascodaGama's picture
VascodaGama
Posts: 2987
Joined: Nov 2010

Neha,

I am sorry for the situation. From your above description I cannot understand if his doctor is declaring recurrence or if he is recommending a neoadjuvant therapy. You have not shared details of the initial diagnosis (PSA, DRE, symptoms, image exams, clinical stage, etc) so I would think that the doctor is talking about a neoadjuvant treatment that has already been planned before the surgery. I base my opinion on the biopsy results that found 12 positive cores out of 12 cores. This is a voluminous cancer with a Gleason rate 4 attached, therefor an high indication for existing spread. to such extent, if metastases have been detected before intervention, then surgery was done with the intent of debulking the big tumour which will be followed with an attack with radiation RT (this is a common procedure). The protocol can also include a period of hormonal treatment, administered before and after RT.

If in fact your father is experiencing recurrence (the PSA is higher than 0.2 ng/ml) indicating a failed surgery, then he should try finding the extent of the disease and decide on a salvage treatment most suitable for his case. Surely all should be well studied taking into consideration any other illness present or expected to occur. Chemotherapy or hormonal treatment is palliative and may be proper if the cancer has metastasized to bone. At 76 years old he can try radiation but this should be done with apparent targets. Guessing the location may lead to worse outcomes and your dad would risk additional side effects over the ones obtained from the surgery.

 I would recommend you to get second opinions from a medical oncologist. You also should read about the consequences of each therapy, its risks and side effects, before deciding. Your dad's quality of life is in jeopardy.

Best wishes,

VGama

Clevelandguy
Posts: 440
Joined: Jun 2015

Hi,

Sorry to hear about your Dad's situation.  Sounds like the next step would be one of the various radiation treatments to try and slow down the cancer.  Hormone therapy might also be in your Dad's future if he wants to go that route.  I am sure your oncologist can provide info on the various treaments and their side effects.  As far as the urine leakage it varies per person. Some are leak free in a few months other take up to two years.  It should reduce over time as the surgery area heals.  I went from a diaper with a pad inside to a light pad after two years.  Still have a little stress leakage(drops) when I move an odd way or strain.  How can you have Extraprostatic extension and still have negative margins?  Hope for the best and make an educated decison on the next course of treatment, keep on fighting.................

Dave 3+4

RobLee's picture
RobLee
Posts: 259
Joined: Feb 2017

Clevelandguy, the EPE tissue can be cut out during prostatectomy. Generally this is known as using a broad cut. Typically +SM occurs when the tumor is apical where the surgeon would have difficulty discerning the difference between prostatic tissues.

Neha5
Posts: 2
Joined: Aug 2017

Hi All

Thanks for the responses. Just to give a few more details:

Prior to surgery the biopsy revealed a Gleason score of 7 however there was no metastatis indicated, which is why we went ahead with the surgery.

My father is otherwise an ex army man and in good physical condition.

The post surgery biopsy report however mentions a Gleason score of 8 , EPE positive and negative margins (which is what is confusing me with my little knowledge).

The staging has been given as T3bN0Mx which I was told means lymph nodes are clear and there is no metastatis. The surgeon has told us to do a PSA count after 6 weeks and then after 3 months. The need for ADT will be decieded after 3 months.

Do let me know if anyone understands what this means.

Thanks again for all your responses.

 

RobLee's picture
RobLee
Posts: 259
Joined: Feb 2017

T3B is a specific stage for seminal vesicle invasion. Without SVI he would be T3a. SVI is an adverse pathology and is considered to be very high risk, referred to as locally advanced, and almost always requires post-prostatectomy radiation.  In fact, I myself am T3B, had my prostatectomy one year ago today, have been on hormone deprivation therapy all of this year and am now in my third week of 39 daily IMRT adjuvant radiation treatments. Your father can probably expect to go thru the same regimen.

Incidentally, the 'N0' indicated that lymph nodes were sampled and were negative, and the Mx indicates that distant metastasis has not been determined. Good luck to you and your DAD!

Weird Harold
Posts: 11
Joined: Jun 2017

Hello Neha5,

I am also a pT3b with a G7, age 56 in 2015. Had all the bad pathology, but lymph nodes were negative. My uro surgeon was talking about adjuvant radiation at our first post surgery consult. I had EBRT one year later. One and a half years later my PSA has stayed even at .1.  I have the usual ED problems, but I am fine with medication.  I use 1 pad per day for stress incontenance. Overall I am happy with the double dose of treatment.

W.H.

RobLee's picture
RobLee
Posts: 259
Joined: Feb 2017

In your original post you stated: "Semnical vesicles are clear. Margins are negative", but then this morning you said that he is T3B.  As mentioned earlier, T3B means that there is seminial vesicle invasion (you can look up the TNM stages for prostate cancer). So my point is, which is it?

Actually, SVI is in some ways better than having a positive surgical margin. In the case of SVI, you already know that you are going to require radiation. With a +SM one never knows if or when the PSA will begin to rise again.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3274
Joined: May 2012

Neha,

Like several of the others, exactly what you are saying is unclear.  I assume you are in the US, where virtually all Prostectomies involve removal of the Seminal Vesicals, so some involvement in there (If there was such) would usually be unproblematic.

Following failure of surgery, if no distant metastasis has occured, Radiation can often be curative.  The 3 month wait is probably reasonable.   HT is possible, and maybe even likely, but HT is never curative, ever.  If his doctors feel he can have the disease totally eradicated, then he will have to receive RT.

max

VascodaGama's picture
VascodaGama
Posts: 2987
Joined: Nov 2010

Neha,

Rob above is giving you the meaning of the stage T3bN0Mx. I assume this to be the clinical stage before surgery as it would turn into pT3bpN0pMx if found after surgery (pathological stage). To such extent, metastases were assumed to exist before the surgery therefore confirming my above initial post. His doctor was aware of the high probability that your dad would need further intervention. He did surgery with intent of debulking the bigger tumor, and may be planning to administer radiation RT as an adjuvant treatment when the time is right, probably starting it in four/six months. The hormonal therapy ADT will be done before that (RT) and continue during a period that can last two years depending on the case. ADT before RT is considered optimal as it sensitizes the cancerous cells to absorb radiation better, leading to better RT outcomes. 

In regards to the confusing diagnosis of "EPE positive and negative margins"; this means that extra prostatic extensions were found but that the margins at the incision (the two typical incisions done to dissect the prostate, at the base just next to the bladder and at the colon) were not found with cancer. In other words EPE exists but not at those places. The radiologist will use this information for the isodoseplanning.

There are many ways to treat PCa and many guys with the same experience of that of your dad have opt for similar treatment. Nobody can tell which option would provide better outcomes but duplicating therapies will surely add more risks and side effects to the patient leading to the prejudice of his quality of life.
Your dad will have to care more for the side effects than for the cancer. I recommend you to be vigilant with his other health aspects that can deteriorate due to the sequential therapies, if any. Bone health, heart health, diabetes, kidney disease, etc, must be checked periodically. Radiation should be administered after a colonoscopy to identify any case of ulcerative colitis. ADT is linked to bone loss so that a DEXA scan should be done in advanced and any osteopenia should be cared properly, along the ADT period.

A medical oncologist would improve his vigilance and continued treatment.

Best wishes,

VGama

 

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