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Path report & Robotic Surgery - help please?

LeoJ
Posts: 13
Joined: May 2018

Age 70.  From the recent prostate biopsies:

  1.   acinar adenocrcinoma
  2.   involving five of seven biopsy sites
  3.   highest Gleason ISUP grade group 3, GleasonSscore 4 + 3 = 7
  4.   ISUP group 2,  Gleason Score 3 + 4 = 7
  5.   perineural infiltration present

Tumour from 60%, 75%, 80% and 95% of the core tissue removed.  Also, comment, 'No evidence of perineural infiltration or extraprostatic extension seen.  A CT/PET showed some 'activity' in a lymph node.  However the urologist's thinking is it is probably not related, and only direct observation, the robotic surgery, would prove.  Recent MRI - 2cmX2cm tumour.  General health is good but well overweight. 

Robotic surgery is my best option at 70, it appears.  What thoughts and experiences please?

 

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Leo,

I am sorry for the situation. I wonder if your doctor has been fair enough to you and told you everything. The fact is that robotic surgery would be recommended if the cancer is whole contained in the prostate gland, but the data you share here indicates otherwise. Gleason 7 (4+3) is aggressive and got high risks for having spread, probably to the lymph nodes which were identified in the scan.

In your shoes I would firstly try to locate the bandit to obtain a due clinical stage. You should get firstly second opinions from other specialists. Get your own List of Questions for the doctors you may be visiting.

I read in your "my page" that you did a colectomy (T1 cancer) sometime in 2017 and that you have experienced pain (May 2018) in the lower abdomen. I wonder if you got details on the type of the cancer that was removed from the colon. This time you are informing about the findings of prostate cancer via a biopsy (five positive cores out of seven), which data added to the finding of an affected lymph node (identified in a PET/CT exam) could mean that both cases (colon and prostate) are the same thing. The treatment you have done (2017) could also affect the choice of the treatment you will be choosing.

If such is confirmed then you should be treated as a stage 4 patient, using a more aggressive mean of therapy (combination of hormonal plus a prime treatment). Removing the prostate alone would not cure you. The intervention would just debulk part of the problem and leave you with the side effects.

Treatments for prostate cancer are linked to risks (cumulative by each therapy we do) that will deteriorate the quality of life of the patient. Surely we need to treat but we should choose those depending on the side effects. You should know the details involved in each therapy before deciding.

Here are reading materials that may be helpful for you;

http://www.ccjm.org/index.php?id=105745&tx_ttnews%5Btt_news%5D=365457&cHash=b0ba623513502d3944c80bc1935e0958

http://www.lef.org/Protocols/Cancer/Prostate-Cancer-Prevention/Page-01

List of questions when meeting the doctors;

http://csn.cancer.org/node/224280

http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-talking-with-doctor

http://www.cancer.net/patient/All+About+Cancer/Newly+Diagnosed/Questions+to+Ask+the+Doctor

Graphical representation of Treatment Options;

https://prostatecancerfree.org/compare-prostate-cancer-treatments-high-risk/

Best wishes and luck in your journey.

VGama

lighterwood67's picture
lighterwood67
Posts: 213
Joined: Feb 2018

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.

LeoJ
Posts: 13
Joined: May 2018

how to look up lighterwood?  Thanks

Old Salt
Posts: 720
Joined: Aug 2014

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).

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

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
Posts: 13
Joined: May 2018

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.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

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
Posts: 13
Joined: May 2018

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.  

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

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
Posts: 13
Joined: May 2018

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 :)

lighterwood67's picture
lighterwood67
Posts: 213
Joined: Feb 2018

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.  

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

Leo, my DaVinci did not involve the removal of any nodes. The surgeon told me that lymph node removal would not be necessary.  Pathology study of the removed gland confirmed to him that there was no need for node removal also. And the radiation oncologist told me when I consulted with him that my results indicated that a pre-treatment MRI, bone scan, or PET would all be a waste of time and money.  These tests reveal nothing except in cases of disease that is well advanced.

In your case there will be node removal (I would be shocked otherwise). This involves a little more probing, but does not dramatically increase the surgery.  The nodes adjacent to the gland are referred to as 'sentinel', in the sense that they 'stand guard', or give doctors an early warning of spread (SLNB: 'Sentinel lymph node biopsy')

All DaVincis today involve removal of the prostate and the seminal vesicals. The seminal vesicles are two small, wing-shaped glands that sort of wrap around the base of the bladder, that secrete fluids into the prostate gland.  Nodes are discretionary, depending on the biopsy report and other particulars both before surgery and during.  If a doctor suspected that node removal were not necessary prior to surgery but then saw someting suspicious while inside, he would go ahead and take some. They err on the side of caution, and if anything warrants node removal, it is performed.

LeoJ
Posts: 13
Joined: May 2018

Pelvic lymph nodes to be removed.

Thanks lighterwood and max.

lighterwood, no radiology proposed in my case ATM. 

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

I am glad for knowing that you have reached to a decision. If lymph nodes dissection makes part of the protocol then the open type surgery may be a better option to dissect those deep nodes out of the reach of the robot's arms. It will take you longer to recover (add 3 days in the hospital) but it will be worth the effort. Discuss the matter with your surgeon in your next meeting.

Best,

VG

 

LeoJ
Posts: 13
Joined: May 2018

VG,  Hi and thanks.

The surgeon did not mention any deep nodes and it will be robotic surgery.  There is no plan for another consultation prior to the admission.

I am lost as to what to do about the deep nodes.

hopeful and opt...
Posts: 2226
Joined: Apr 2009

Recommend that you consult with specialists such as a radiation oncologist and medical oncologist.

I would seek diagnostic tests such as a T3 MRI and a PET scan in order to help determine if there is extracapsular extension, and if so where the cancer exists for best treatment.

Surgery is a localized treatment, and if the cancer is outside the prostate additional treatment such as radiation and or hormone treatment will also be necessary. Side effects of various treatments are cummulative. 

As far as treatment, there is a difference among doctors, some being "artists" while most other not. As far as surgery there is a steep learning curve, requiring at least several hundred procedures for a fellowship trained surgeon.......i wonder how competent the surgeon who recommend surgery to you, and if he wishes to perform same instead of referring you to an artist.

radiation treats the prostate plus surrounding area around the prostate, which is preferred in more advanced cases where the cancer may have escaped the prostate,  since there will be one treatment, not more than one treatment. generally a combination of radiation and hormone treatment is advised in these cases.

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

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 

LeoJ
Posts: 13
Joined: May 2018

Hi hopeful.  A good nick and sentiment.  Hello too to VGama and thansks.

I had a prostate MRI which showed a problem area 20mmx20mm (3/4"x3/4") within the prostate.  Must have been a large prostate. The previous TUR(P) procedure removed  lot of tissue but only glance the tumour, which I believe was on the other side (and the 'usual' side for cancer) to that where the TUR(P) is bored.

Following that, Gallium 68 labelled PSMA PET imaging was performed.  As well as the location within the prostate, some activity* was seen in adjacent lymph node/s.  *activity - should that always be qualified as apparent given the limitations of imaging?

Robotic was chosen for accuracy and the surgeon is very well experienced in that.

hopeful and opt...
Posts: 2226
Joined: Apr 2009

"Robotic was chosen for accuracy and the surgeon is very well experienced in that."

Actually radiation is very acurate, and there is less margin than surgery, generally it is 01 to 02 mm.

There is a variance of surgical margin among surgeons....you may wish to ask the surgeon what his surgical margin is. ( by the way, in some major hospitals, with the use of computers, the surgical margin is less.. Computer generated is .06 , a very experienced surgeon not using computer is about .10 to.12 , others have greater surgical margins.

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Leo,

You are informing us on your diagnosis in bits and pieces. Do you have more at the bottom of your pocket?

It seems you like accuracy and you couldn't have choosen better than the Ga-68 PSMA PET exam to locate the bandit. This is specific to prostate cancer and the results are to be trusted. The lymph nodes found with "some activity" are the ones to be removed or radiated. Even the ones closed to these but not in activity (as seen in the scan) should also be addressed.

This diagnostic of lymph nodes involvement increases the risks to metastases, but these were not identified in far places by the PSMA PET which makes your case localized but not contained (T3c N1 M0). Definitively, the treatment protocol should include the affected LN. I am sorry to say this but for the sake of those newbies in similar shoes following your thread I would recommend RT approaches in such diagnosis.

You add the question: *activity - should that always be qualified as apparent given the limitations of imaging? 

Well, you are right about the limitation in detecting PCa by the traditional CT, MRI and Bone scan images but the specificity of the PET provided by a PSMA isotope is real as it identifies prostatic cells. These should never be in activity in the lymph nodes unless they represent metastases. If, for whatever reason, they are not addressed in your therapy this time, one will risks future recurrences in need of a salvage treatment.

Your surgeon could be the best in robotic treatments but surgery also got limitations; they do not treat metastases. Surely he would only recommend you his trade, surgery. A radiologist would also do the same recommending radiotherapy, which would have a series of other unpleasant side effects. It is our duty to educate on the matter and decide in what to chose. We will sign an agreement before intervention relieving the doctor from any responsibility.

I hope you the best.

VG

LeoJ
Posts: 13
Joined: May 2018

I have no medical knowledge and I am responding as best I can to the most kind and very helpful comments on here.  The diagnosis of prostate cancer is very recent.  Next problem is that the available information on PC for the public and sufferers is very general and books may be out of date.  My unfamiliarity with medical and imaging terms and of course, how to work out what is 'best'.  Nothing is up sleeve (or in the pocket) so to speak.  But I am well out of my depth as any new to this diagnosis. 

What has weighed heavily in my acceptance of the radical surgery is the medical advice (from surgeons) that it holds the best prospect for me.   Secondly, that radium treatment will likely rule out later surgery.

Surgery first, get lab report of tissue (lymph in particular I think) and hopefully, a cure nd watgch and wit with regular PSA checks.  Or most of the problem area removed and far less 'leakage' to cause metatses elsewhere in the future. [this last sentence is my assumption] 

VascodaGama's picture
VascodaGama
Posts: 3033
Joined: Nov 2010

Leo,

Your choice is good and I believe that the doctor will care about the LN identified in the scan. I hope that RP eliminates the bandit for good and that you tell us about the zeros latter. Just keep checking the PSA and try follow the requirements to recover from the side effects.

Best wishes for the "D" day (today?).

VG 

LeoJ
Posts: 13
Joined: May 2018

Thank you.  Some time yet, still being sorted and I will be on the site.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3313
Joined: May 2012

Leo your most recent comment (Sept 3) made me feel guilty about this site generally.  It is true that newcomers routinely feel information overload, and we use "shop talk" too much.   And then beyond that, there are a few regulars who are explicit "fans" or "advocates" for their preferred way of doing things, but I have not seen you receive any commments thus far that are more "booster club" than science.

It seems to me that you are making great progress and are better informed than most starters.  In my own case, I went to a radiation oncologist first, read all about that, really liked the R.O., and was decided on radiation until I met my surgeon. That changed everything. I was more or less back to square one, and continued reading. The more I studied, the less clear it all became.  Eventually I realized that there are no perfect choices, but rather in some sense too many choices.  At some point every man must make his choice and then feel good about it.  The saddest cases are guys who study a lot, eventually make a choice that they are not sure about, and then have negative outcomes. They seem never able later to be ok with the decisions they made.    Do not be them.

As Vasco and I wrote above, if surgery is your decision for the good reasons you listed, then go with it and be thankful forever after, regardless.  There are some objective facotrs that render one therapy suitable for one man but not another. But these cases are less common, and the doctors involved are ordinarily (almost always, I think) honest in handing off a patient to someone else.  An 80 year old man with severe heart disease, for instance, is not going to find a surgeon will do a R.P. him...his surgeon would refer him elsewhere, every time.

Continuing to learn is always a good thing. Online, use only university or medical center sites though, since they are the most objective and honest, with the best writers.  Places like MD Anderson, Sloan Kettering, The Cleveland Clinic, Johns Hopkins Hospital -- places like that.  And of course the American Cancer Society. 

max

LeoJ
Posts: 13
Joined: May 2018

My experience on here has been very positive.  I am very thankful that so many are prepared to be of such service to others and to give some advice - which is often lacking, leaving one even more at sea.  It's all good.

 

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