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Pathology after 3/2/20 RP. Some questions.

jayjelinek
Posts: 4
Joined: Mar 2020

62 years. Pathology shows 3+4 ISUP group grade 2 disease with perineural invasion, focal EPE on left posterolateral region, and focal lymphovascular space invasion noted.

Seminal vesicles negative. All surgical margins negative. 5 lymph nodes removed, all negative.

My main question is what does "focal lymphovascular space invasion" really signify if the removed lymph nodes are negative? Predictive of higher recurrence risk? Thought I had read up a lot on this before the RP but have never encountered the lymphovascular space invasion term before...

Thanks in advance for any insights! Jay

eonore
Posts: 89
Joined: Jun 2017

Hi Jay, 

First of all congratulations on getting past your surgery.  I wish you a speedy and uneventful recovery.

While I am no expert, focal lymphovascular invasion means that cancer cells were detected in surrounding lymph and vascular tissue.  The major takeaway is that you are at increased risk of Bcr.  Your extracapular extension means the same thing.  You need to monitor your Psa frequently using the ultra sensitive test.  I suspect that given your relatively low Gleason score, adjuntive radiation will not be recommended, but this is a conversation you need to have, both with your surgeon, and also I would line up a consult with a top notch radiation oncologist.  I don't think that this is a catastrophe, but you need to be vigilant.

 

Eric

jayjelinek
Posts: 4
Joined: Mar 2020

Eric,

Thanks for the insights. You corroborated almost exactly what my surgeon already said. I am currently arranging a consult with a radiation oncologist also, although from all my review of the recent research adjuvant radiation therapy is likely not happening immediately.

My RARP went really well, virtually pain free 8 days later. Main issue now is that prior to this procedure I had an asymptomatic inguinal hernia (only knew about it from CAT scan, was not visible/painful). No more. Noticable bulge/some pain totally distinct from the incision sites. Looks like that will have to be cleaned up.

Didn't really want to become a member of this club, but now that I'm here looking forward to participating!

Jay

Clevelandguy
Posts: 552
Joined: Jun 2015

Hi Jay,

I also was 3+4 with perineural invasion and after after 5 yrs. my PSA is still undectable. If it was me and I am no doctor I would wait for a couple of PSA readings to see where you are at.  Radiation would probably be the next step if you still have a detectable PSA but why go that route unless needed.  Food for thought, good luck.

Dave 3+4

jayjelinek
Posts: 4
Joined: Mar 2020

My concern specifically is the EPE positive and the lymphovascular space positive pathology results. These seem to indicate higher risk of recurrence than just perineural invasion. You're right not to go down the radiation road unless needed, but there seems to be some research indicating early adjuvant radiation therapy may actually be beneficial in cases like mine, like Eric noted. But not conclusive. Continuing to look at this. Jay

Hellostone
Posts: 22
Joined: Jan 2020

I'm a new guy doing his research so take this with a huge boatload of salt, but I recall hearing that at the 2019 ESMO meeting, the question of adjuvant vs. salvage post-surgery radiation was discussed in the RADICALS-RT and ARTISTIC trials.  My layman's takeaway was that early salvage radation was just as good as adjuvant radiation -- meaning that post-RP radiation could wait until PSA began to rise (no higher than 0.2) before initiating radiotherapy treatment, rather than automatically turning to adjuvant radiation soon after surgery.  Again, this is just my impression as a non-medical guy.  Here are a few links I looked at:

https://www.urotoday.com/conference-highlights/esmo-2019/esmo-2019-prostate-cancer/115205-esmo-2019-adjuvant-or-salvage-radiotherapy-for-the-treatment-of-localized-prostate-cancer-a-prospectively-planned-aggregate-data-meta-analysis.html

https://www.ascopost.com/news/september-2019/men-with-prostate-cancer-can-be-spared-radiotherapy-after-surgery/

http://dailyreporter.esmo.org/prostate-cancer-what-is-the-optimal-timing-for-radiotherapy/

 https://ascopost.com/issues/october-25-2019/studies-suggest-early-salvage-radiotherapy-may-be-preferable-to-adjuvant-radiotherapy-after-prostatectomy/

 

jayjelinek
Posts: 4
Joined: Mar 2020

Hellostone,

Great links! For someone like me whose main way to cope with my PCa is to learn as much as I can about my options looking forward, this is much appreciated!

Jay

VascodaGama's picture
VascodaGama
Posts: 3191
Joined: Nov 2010

Jay,

According to the information you share above, you are now three weeks post op. I would think that the surgery option was decided based on the information gathered initially and chosen as the best way leading to cure. Now you need to wait and give time to verify if surgery was successful in freeing you from the cancer. Surely the pathologist's report on the gland's specimen and dissected tissues (out of your body) is taken into consideration in any future decision for additional treatment but the contents by itself doesn't lead to a conclusion.
The report identifies cancer at gland's' shell (EPE) and at the outer tissues encompassing the lymph nodes but one doesn't know if malignant cells were left behind as they vacuum the area cleaning all debris and blood at the cavity.

You could be cured by now or you may need a salvage treatment, but such should follow reasonable principles not just based on what was found by the pathologist. Adjuvant treatment (radiation) is typically recommended when the conditions verified before surgery (RP) have suggested high probabilities for EPE. That means that such patient had conditions appropriated for a prime radiotherapy (RT) or a combination treatment with RP+RT. In your case, going adjuvant may not lead to a successful end. Apart from that, not all EPE cases recur and one may risk the side effects of two treatments unnecessarily.

Without knowing your previous diagnosis, clinical stage and data from initial tests and exams, I only can say that you better give time to verify if recurrence occurs, deciding on the matter then. You can test already the PSA as the body usually takes two weeks to clean up circulating serum. This should be closer to 0.05 ng/ml and stay there at three months post op.

VascodaGama's picture
VascodaGama
Posts: 3191
Joined: Nov 2010

Jay,

Got some prohibition from the site in posting my whole comment above. I want to add;

As commented above by Hellostone, they found from trials that earlier salvage radiation therapy (delivered in times similar to adjuvant therapy) do not better the results of SRT done when recurrence is declared.

I would recommend you to investigate further into the situation and discuss with your main doctor or get advice from a medical oncologist.

Best wishes for remission levels in your first PSA post RP.

VGama 

 

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