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PSA 32 Gleason 3+4=7 Localized

IndyJoe
Posts: 7
Joined: Nov 2019

 

Hi gang,

 Really appreciate all the great info I have recently received on this forum.  You all rock !!  My situation is below.  RP lined up for mid Dec. Thankful for the clean scans of course which found no obvious spreading.  Still, I can't help but to think that once I'm past the RP, I may very well be in line for follow-up treatments especially given the high PSA and all cores being positive.  Curious on thoughts on this if any of you have them.....Thanks  

  

Age - 50 

PSA (32) – Checked Twice 

Biopsy Positive – 12 of 12 Cores – Gleason 7 (3+4) – Avg 90% 3 / 10% 4 

Bone Scan – Clean 

CT Scan - Clean

 

Clevelandguy
Posts: 473
Joined: Jun 2015

Hi Indy,

Follow-up treatments will depend on the disection results after they remove your Prostate.  If it comes back all contained and your Prostate bed looks clean you might be in good shape.  Sounds like with all cores being positive at around 90% that the cancer was getting close to leaving the barn.  Glad your getting it out now.........

I was 3+4 with plueral neural invasion, 5 years later I still have undetectable PSA, so there is hope.

Dave 3-4

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3329
Joined: May 2012

Indy, I agree with all Cleveland said. After the gland is removed, the patholgists will study it in the lab in microscopic detail.  The urologist will then have a much clearer view regarding possible metastasis.    IF there is definite metastasis, you will almost certainly receive adjuvant radiation therapy.  And, it is possible, given the PSA level and volumetric results that even if there is no clear metastasis to go ahead with precautionary adjuvant radiation.   So, everything depends on the pathology report and, to some extent, the judgement of the surgeon.

 

VascodaGama's picture
VascodaGama
Posts: 3050
Joined: Nov 2010

Indy,

In your shoes, apart from investigating on the treatment consequences, I would check deeply the results of the exams that made you to decide on RP. Sincerely, your comment makes me to think that you are more playing roulette than on the right track.

You say; " RP lined up for mid Dec. Thankful for the clean scans of course which found no obvious spreading", but neither Bone nor CT scans are that accurate to assure a clean localized environment. You also say that you expect to be "...  in line for follow-up treatments", meaning that you know or was informed that RP may not be the best option. In such regard my opinion is that you may opt for radiation from the very start, avoiding the unnecessary risks from two treatments (RP plus RT).

I was also 50 years old and asymptomatic when diagnosed with PCa. My life at the time was at its best, healthy and successful professionally. The bandit was not causing me any trouble but the high PSA (22.4 ng/ml) and the positive biopsy (all 6/6 cores) made me to recognize that I needed to treat. After investigations, my choice was RP not for the high PSA but for the negative scans (like yours) and the low aggressive Gleason score 5 (2+3). Surely I also played roulette (all positive cores have a 99% possibility of spread) and lost because RP did nothing to eliminate the problem but set me with the side effects typical in prostatectomies, wiping out my quality of life. My idea on health problems at my age was as simple as that of taking a pill to get cured. However, Prostatectomies and/or Radiotherapies are not that simple. It involves risks and causes permanent side effects that we should be aware of before committing. You family will be affected too so that they should take part in the final decision too.

In my lay view of your case, I attribute the high PSA to the high volume of existing low aggressive Gleason rate 3 cancerous cells. These types of cells produce more PSA serum than the more aggressive siblings. Gleason rates of 4 are risky and more prone to spread rapidly but rate 3 cells, though less aggresive and more indolent, may also spread to other localized tissues. You can get rid of the whole gland (the bigger tumour) dissecting it via surgery or you can target the whole gland with radiation that can be delivered wider covering surrounding tissues in the same process.

I disagree on the idea of having surgery for the simple purpose of checking the whole gland under the microscope. It will not provide any additional information that could influence on a decision in a future salvage treatment. Radiotherapy as a salvage treatment got the same successful results if done earlier or latter, independent of what the pathological report describes on the whole gland examination. One needs the right timing at the cells divisions to achive the perfect kill with radiation.
I would recommend you to get a PET scan and get second opinions from specialists in both RP and RT. A genetic test can also add more information on your clinical stage. Surely PET scans may also provide false negatives but these are the most advanced image exams today in diagnosing PCa. At least one has the feeling that one has done the best at its disposal before deciding.

Best wishes and luck in your journey.

VGama

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3329
Joined: May 2012

I would like to post a short corrective or clarification:  I have never recommended RP as the first-line modality of choice because of gland pathology afterward.  I noted that, if selected, it is highly valuable afterward in future decision-making.  Conversely, first-line RT predictably sends PSA into oscillations without any form of clear meaning, sometimes for as long as two years prior to establishment of a nadir.    A lab dissection of the gland is probably 100 times more accurate and detailed than any current form of pre-treatment biopsy available. 

Bless your choice, Indy, and RP and RT famously have approximately equal clinical outcomes in cases that do not present metastasis.   In cases where there is, or very likely is, metastasis, radiation is considered by most autorities as the preferred choice.

 

Steve1961
Posts: 250
Joined: Dec 2017

 Taking out the gland and sending it to the lab and getting a full report to me now that I did not do that I wish I had it removed it would definitely bring me peace of mind one way or the other. They say knowing is half the battle it right now since I did not remove it I don’t know Jack I’m just hoping that did not escape where is it I took it out I would know for sure one way or the other so I totally disagree about making a primary choice based on the fact of just being able to send it to the lab ..that is a huge deal 

IndyJoe
Posts: 7
Joined: Nov 2019

Hi all,

Thanks everyone for the quick turn around with your comments.  Some of the detail you provided is fantastic.  Most definitely gives me some things to think about and possible follow-up on.  I am rushing off to work now but definitely plan to more thoroughly read these tonight and will reply accordingly.  

Georges Calvez
Posts: 308
Joined: Sep 2018

Hi Joe,

I had a pretty advanced case so I did the triple.
The advantage is that you remove the cancerous prostate before you start the RT so you do not have complications as the cells die and the gland turns fibrous.
However you are doing a prostatectomy plus RT and the RT tends to exacerbate problems like incontinence, I was lucky but more men have more problems with this than with a simple prostatectomy.
I suspect that your surgeon is planning on a non nerve sparing prostatectomy so you are not going to have a natural erection again.
Some men manage to do RT with ADT and manage to preserve some sexual potency although this may diminish with time.

Best wishes,

Georges

VascodaGama's picture
VascodaGama
Posts: 3050
Joined: Nov 2010

MAX,

Thanks for adding the comment clarifying the importance of the pathologist’s report after surgery. I have dropped the above comment on your post to exactly clarify that the choice of prostatectomies should not be dependent on such idea of having the whole gland out in hand to check if the surgeon’s clinical stage (before RP) was in fact correct. We have seen repeatedly guys posting here on the matter, who believe that choosing RP to get a good look on the gland   is better than other modalities of treatment. This is a total erroneous way of thinking when deciding on a therapy.

The Pathologist’s report after a radical prostatectomy is important to judge the risks for existing metastases and to determine prognosis but it does not provide significant details to single out a type of salvage treatment or the timing when it should be done. The main items in the report will be on Extracapsular Extension, Seminal Vesicle Invasion, Positive Margins, Gleason Score and Type of Adenocarcinoma confirmation, and findings of other particulars of existing tissues. They also write about findings regarding the analysis done on lymph nodes if any has been dissected too. These are all relevant items that should be evaluated before the initial treatment, not after it.

In my view, the decision for an adjuvant treatment post prime therapy should be done before anything is executed. Salvage treatments are decided upon confirmed recurrences. The pathological stage (after RP) will identify those that have the risk to recur later but it is via the PSA that doctors make the decision on the timing to deliver such a treatment. The combination treatment (RP + RT) of Georges is a good example of proper care. I believe that his team of doctors based their decision on the data collected during the diagnosis process. They did not identify metastases initially but his case was so risky that the combination treatment looked to be the best option from the very start. RP followed by adjuvant RT has the higher possibilities for a successful outcome in high Gleason rates of 4 and 5.

In IndyJoe’s case with a Gleason score of 7 (3+4) where the rate 3 covers 90% of the gland, the intermediate risk weighs more in the decision process than the high risk poorly differentiated rates. This is a case that deserves more time to certify a due clinical stage before deciding on that treatment that would give higher hope of success. The biopsy showed a totally infested gland which diagnosis provides high probabilities for existing extracapsular extensions. In such cases many doctors discard the capability of RP alone which may be Joe’s doctor opinion by suggesting that he might need additional treatment if he decides in a radical prostatectomy. That is what you say above “… In cases where there is, or very likely is, metastasis, radiation is considered by most authorities as the preferred choice”.
Combination therapies for low or intermediate risk cases involve usually the hormonal component (ADT) added to a prime radical (RP or RT).

Best,

VGama 

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3329
Joined: May 2012

V,

In the US, kids have an acronym "BFF": Best Friends Forever.  It is my wish and opinion for the two of us....

IndyJoe
Posts: 7
Joined: Nov 2019

Guys,

Thanks again for all your comments and speaking from your personal experiences.  Some really interesting points are being shared and I do appreciate them all, even the counter points.  My Urologist strongly recomments the robot-assisted RP for me and after all the reasearch I've done, it still feels like the right choice for me.  The shire volume of cancer in the glad was a strong decision marker for him.  I am having an MRI on Mon that will be yet be another data point to review and confirm this direction.  In terms of post surgery treatment, he did not indicate one way or another if this would be needed.  I'm just trying to prepare myself for that possibility.  It sounds like his logic is a lot like what is described above by some of you, review gland post surgery getting all the data from that and start tracking PSA.  I figured this would be the case and does make sense.  In terms of going the RP route, I really do like the option of having additional bullets in the chamber (such as RT) post surgery.  That said, I will be doing more deep research this weekend as I'm sure you all have done as well. 

Thanks again...Joe

 

 

 

 

 

   

IndyJoe
Posts: 7
Joined: Nov 2019

Right lateral base – Gleason 7 (3+4) – 90% tissue involved – Gleason 4 - 10%

Right lateral mid – Gleason 7 (3+4) – 95% tissue involved – Gleason 4 – 10%

Right lateral apex – Gleason 7 (3+4) – 90% tissue involved – Gleason 4 – 5%

Right base – Gleason 7 (3+4) – 70% tissue involved – Gleason 4 – 5%

Right mid – Gleason 7 (3+4) – 95% tissue involved – Gleason 4 – 5%

Right apex – Gleason 7 (3+4) – 95% tissue involved – Gleason 4 – 5%

Left lateral base – Gleason 6 (3+3) – 5% tissue involved – Gleason 4 – 0%

Left Lateral mid – Gleason 6 (3+3) – 2% tissue involved – Gleason 4 – 0%

Left lateral apex – Gleason 7 (3+4) – 30% tissue involved – Gleason 4 – 5%

Left base – Gleason 6 (3+3) – 10% tissue involved – Gleason 4 – 0%

Left mid – Gleason 7 (3+4) – 40% tissue involved – Gleason 4 – 5%

Left apex – Gleason 7 (3+4) – 50% tissue involved – Gleason 4 – 10%

 

Clevelandguy
Posts: 473
Joined: Jun 2015

Hi,

If you still have time then a second opinion from a different Urologist and hospital system might be a good idea after you complete your MRI.  The guys above are correct, treatments stacked onto other treatments do make the recovery worse. Good doctors and good hospital systems most of the time will keep the side effects minimal.  But then again if it was all inside of the Prostate (biopsy confirmed) then hopefully you will be done(the best outcome in my opinion). Whether you choose radiation or surgery there will be side effects.

Dave 3+4

 

VascodaGama's picture
VascodaGama
Posts: 3050
Joined: Nov 2010

Indy,

The MRI is super. You’re doing well in gathering more information on your status and the treatments. It will give you more confidence in what you choose. It is common to spend over two, three months in researches to get to a decision.
Take your time and get second opinions at reliable hospitals. Prostate cancer does not spread overnight so that you can choose the best timing for the D-day. I also would look for facilities and doctors with loads of experience in treating PCa. There is a difference in outcomes proportional to their skills.

Wishing you luck.

VG

 

IndyJoe
Posts: 7
Joined: Nov 2019

Thanks again guys for your comments and words of encouragement.  Means a lot.  Will report back post MRI.  Also lining up a second opinion which I will be following through on.  Enjoy the rest of the weekend !!

Georges Calvez
Posts: 308
Joined: Sep 2018

Hi there,

I think there are strong parallels between my case and Joe's.He is a 7a and I was a 7b but there is a lot of grading in there and you have to allow for the fact that the biopsy is localised samples.
Like me he has a very large tumour but localised , it may be totally organ confined or it may be outside.
But 7a,b's are often quite localised, I have seen examples where the tumour is more advanced and has grown into the bladder wall, etc but there are no distant metastases.
The main side effect of going for straight radiation seems to be urinary restriction.
Here is an example similar to Joe's where the guy went for straight radiation plus ADT.
https://www.yananow.org/display_story.php?id=1636

Best wishes,

Georges

IndyJoe
Posts: 7
Joined: Nov 2019

Thanks for your comments and the link Georges.  I've read a lot of stories from guys having urinary restriction issues during and post radiation.  Information is power and there is a lot of it here.  

Thanks again....Joe 

lighterwood67's picture
lighterwood67
Posts: 222
Joined: Feb 2018

Well, you are doing your homework.  In my case, Gleason 4+3=7.  PSA around 4.72.  I elected RARP.  I did this based on what the doctors told me (both surgeons and onocologists).  This prostate cancer is a moving target.  In some cases, very adaptable and able to continue to sow the seeds of cancer even with treatment.  For now, for almost 2 years my PSA has been non-detectable;  I am fully continent (4 to 6 months after RARP; no pads, nothing right now.)  My ED is still holding around 75%.  So, as mentioned above, the side effects can be devastating.  Just from a RARP, from a physical standpoint you will never be the same (no gland; no seminal vesicles; maybe bladder neck reconstruction; maybe lymph node removal).  In saying all of that, you may have dealt the cancer a knock out curative blow, if the cancer was contained. This decision is up to you.  And you alone.  I talk to what happened to me after a RARP.  I am at Peace with myself.  I live with the side effects as they present themselves and move on.  I do not allow the side effects to impact my Quality of Life.  This is very important.  So take, your time in your decision.  Most of the folks on this site are much more knowledgeable on this subject than me and have significantly contributed to my well-being throughout my journey.  So, good luck on your journey.

IndyJoe
Posts: 7
Joined: Nov 2019

Hey Lighter,

Appreciate you comments on your personal experience and words of encouragement and just like the others above, this mean a lot to me.  Best of luck going foward.  Looks like you are in a good spot right now physically and mentally despite the impact of the RARP.  Thanks again...Joe  

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