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PSA 32 Gleason 3+4=7 Localized

IndyJoe
Posts: 15
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: 505
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: 3364
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: 3118
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...
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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: 280
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: 15
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: 350
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: 3118
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: 3364
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: 15
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: 15
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: 505
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: 3118
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: 15
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: 350
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: 15
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: 239
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: 15
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  

IndyJoe
Posts: 15
Joined: Nov 2019

Hey guys,

Been awhile since I was out here and wanted to provide an update on my status.  The MRI results indicated heavy cancer in the prostrate (which we knew from the biopsy).  It found no indication of spreading beyond the gland or lymphnodes.  With that information and all of the info from previous scans / tests, I made the decision to have the Davinci RP which was executed this past Fri.  Home recovering now.  Catheter comes out this Fri at which time I will learn about the pathology reports which we all know from comments above will set the state for the next set of treatment decisions to be made.  Again, I can't tell you guys enough how much I appreciate you contributing above. Very much appreciated.  Will report back soon.

 

Thanks again....Joe 

Josephg
Posts: 194
Joined: Jan 2013

We will always be here for you, Indy, and I believe that you will always be here for folks who join this Forum after you.

We are Brothers in PCa.

ufknkidding
Posts: 45
Joined: Aug 2019

Congratulations on a successful surgery.  Glad to hear you are home recovering and the cath comes out Friday.  The cath, man I hated that thing.  I am post RARP from 09/2019 so a few months ahead of you.  Recovery gets beter and better each day.  Keep posting through your recovery so we can provide some encouragement and support. You do not need to go through any of this alone and even though family may be nearby, they may not fully understand all your emotions and feelings.  Best wishes and take it day by day.

VascodaGama's picture
VascodaGama
Posts: 3118
Joined: Nov 2010

Indy,

Thanks for updating your story. I am glad for the news and for knowing that you are well. It is better to concentrate now in recuperating fully instead of involving yourself in "... the next set of treatment decisions ". That may not even be necessary; however, recuperation obliges you to be active from the beginning. After RP, among several things, my doctor recommended me daily walks, and after removal of the catheter he suggested sex related activities to avoid atrophy of the penis, using a pump or masturbation (sort of massaging the penis extending it), and taking Viagra twice a week. The purpose is to oxygenate the cavernous areas of the penis filling it with blood. In regards to continence, kegels exercises are recommended but too much of it may lead to other complications. Good diets are also important, in particular if one requires any adjuvant treatment.

Surely the pathological stage will dictate the next step but the PSA is the marker and I believe that your doctor will use it to judge anything for the future. Surgery success is taken when the PSA at one month post op gets into remission levels lower than 0.05 ng/ml. This is the number I expect to read in your next update.

So far you are alive and kicking. Congratulations.

Best wishes

VGama

IndyJoe
Posts: 15
Joined: Nov 2019

Thanks for the detailed post RP info VG.  Very helpful.  It will be interesting to see if my doc takes a similar approach.  Wasn't even thinking about some of this until I read your post.  Thanks again and will most definitely keep you and the gang here posted.    

Sctt_rbrtsn
Posts: 1
Joined: Dec 2019

Hi everyone

 

I am 55 and in march began medical weight loss program. It was a combo of precription app suppressant and TRT. In Sept I began having urinary difficulties, weak stream. Hard to start, etc.. wen to PCP he tested my PSA result was 4.2 from a 1.6 result in Mar when i began program. PCP referred me to urologist. PSA was 4.1 but t level was at 1200. I had stopped TRT month before urologist appt. Uro scheduled me for biopsy dec 9th . End of Nov went back to PCP retested PSA and it had dropped to 2.2. Biopsy results 12 cores positive 25% gleason was 3+4=7 . Digital test before biopsy no lumps found but one side felt hard. Dr ordered bone acan and ct scan as next step. Father was diagnosed at 78 with prostate cancer . 

Im in uncharted water here. How serious does this sound? I was told i was not low or high but at intermediate risk.

Can anyone advise me if next steps and scan tests are normal protocol.  I understand scans will allow uro to grade my tumor and guide him to recommended treatment advise. Otherwis very healthly 6,2" 220 lb man. 

 can anyone advise on questions to ask or next steps i should consider?

what should i get prepared for?

 

thank you!

 

 

IndyJoe
Posts: 15
Joined: Nov 2019

To ensure your post get maximum coverage in this forumn, I would advise you re-post this as a new topic to this prostrate cancer page.  If you are unsure how to do this, just let me know as I am happy to get that started.  Right now, your post is only being seen by those looking at my specifc thread.  It will be best for you to start a new one.  The reason why I say this is because there are so many awesome guys out here with a load of experience that will definitly weigh in on your question.  Sorry to hear about your diagnosis.  My story is above, in this thread.  I just had my prostrate removed last week and the catheter pulled today :).  Anyway, just let me know if you'd like my help is getting your post into a new thread.....

 

Joe

IndyJoe
Posts: 15
Joined: Nov 2019

Hi gang,

To recap, I had a RP performed on 12/12.  PSA prior to the surgery was 32.  I got my hands on the pathology report and below are the highlights, a bit of a mixed bag.  First PSA test post RP is set for late Jan.  Will share more info when I have it.  As always, comments, questions etc are welcomed.

 

Gleason 3+4=7

 

Primary pattern 3 – 50%

 

Secondary pattern 4 – 45%

 

Tertiary pattern 5 – 5%

ISUP/WHO Grade group 2/5

Extraprostatic Extension – Present (Nonfocal)

 

Urinary bladder next invasion – No

 

Seminal Vesicle Invasion – Absent

 

Surgical margin involvement – No

 

Apex involvement – Positive

 

Intraductal carcinoma – Not identified

 

Perineural invasion – Present

 

Lymphovascular invasion (20 Lymph nodes tested) – Absent

 

Other significant findings – None

Pathologic stage – pT3a pN0

 

VascodaGama's picture
VascodaGama
Posts: 3118
Joined: Nov 2010

Indy,

Some doctors would consider adjuvant RT in a case with the characteristics described in your pathological report. The data confirms localized extraprostatic extensions and an existing tertiary grade 5 (aggressive) but it doesn't inform its location. These two items are the baddies in the report, diagnosing a pathological stage of pT3a pN0. They write Gleason 3+4=7 but this would be up graded to Gleason score 8 (3+5) in spite of the low percentage of grade 5 cells.

A considerable number of cases get such classification but there is a difference in the judgment done by the doctors between pT3a pN0 cases with a Gleason score 6 and those (similar to your case) with Gleason score 8 (3+5). I wonder what will be the opinion of your doctor. Some wait and follow the PSA marker, administering a salvage therapy when such becomes required (if ever), and some disregard the PSA marker prefering to administer adjuvant RT as soon as the patient has recuperated from the surgery (typically 1.5 to 2 months post op).

Let's enjoy the festivities and wait for the PSA.

Best wishes for the New Year.

VG

IndyJoe
Posts: 15
Joined: Nov 2019

Thanks for your thoughts on the path report VG.  I was especially interested in your comments regarding the Gleason which confirms what I was thinking as I really didn't understand why they rated it as a 3+4=7 given the breakdown.  I see my doc on 1/22 and we will have the revised PSA results in hand when having that next step conversation.  My sense based on prior converstaions is that he will advise to go active surveillance via PSA marker.  We shall see.  Thanks again for your thoughts and Happy New Year my friend.      

IndyJoe
Posts: 15
Joined: Nov 2019

Hi all,

Quick update on my situation.  My first PSA test following my RP which was approx 6 weeks ago was 0.043 which was measured earlier this week.  I met with my doc who now has me on active surveillance with next test in 3 mos.  As I say most every time I'm out here, Ireally appreciate all the support all of you have given me throughout my journey.  You all are a true blessing to me....Thanks again.

VascodaGama's picture
VascodaGama
Posts: 3118
Joined: Nov 2010

Congratulations for the low PSA. Let's hope for remission forever.

I recall my moments after prostatectomy 20 years ago just two days after op. The surgeon visited the room telling me that he has vacuum well the whole area before stitching me up. It seems that the action was common in open surgeries. The intent was to be certain that no prostatic cells were left behind.
The practice is still used today by some robotic operators in particular to those cases diagnosed with extraprostatic extensions like yours. One is not sure if the RP has cleaned all but one can hope for that.

Best

VG

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