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MSK re-review of biopsy slides - worse

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Posted 2/7/2009 12:50 PM (GMT 0)
The hits just keep on coming.  In the hopes of getting a downgrade of my Gleason, I had my biopsy slides re-reviewed at Sloan-Kettering (Venice, FL is not exactly the healthcare capital of the world).  My reward is that my one 3+4=7 Gleason was changed to 4+3=7.  The other was confirmed at 4+3=7.  Anything else new?  Of course!  A nice little comment at the end of the report.... "Perineural invasion is present".

I'm still holding out hope for robotic RP, now more than ever.  In a few hours, I have a telephone consult with the newly elected Chief of Surgery of Urology at Sloan, James Eastham, MD (I'm glad my son was smart enough to marry a urologic nurse there).

Signature updated but not in the manner I had hoped for.

Tony

Posted 2/7/2009 1:00 PM (GMT 0)
Good luck Tony. Dr. Eastham is a fine man and a very talented one. He is only one of a handful of surgeons in the country that will do salvage surgery. You will be in fine hands with Dr. Eastham if you decide on surgery...I wish we had gone to him BEFORE the radiation. By the way, all of the nurses that we met in his office were really great.....I am sure that we met your daughter inlaw....we were in there so many times.......Diane
Posted 2/7/2009 1:23 PM (GMT 0)
Tony, I realzie that didnt flip the way you wanted or hoped, but still makes you a good candidate for surgery and it should still be contained. My best to you brother.

David in SC
Posted 2/7/2009 1:57 PM (GMT 0)
Thanks to Diane and David.

Diane, during your long and difficult journey, have you and Pete developed a "Monday morning quarterback" preference of one treatment over the others?

Tony
Posted 2/7/2009 2:43 PM (GMT 0)
Good luck to you. My gleason biospy was a 3+4. After surgery, it was upgraded to a 4+4. As David says, you are still a candidate for surgery. Once you make the decision and have a plan you will feel better (at least I did). It is still very stressful but hang in there. Do your research and consult with the doctor's.
Posted 2/7/2009 9:28 PM (GMT 0)
Well, Tony, There is no question that knowing what we do now, we would have had the surgery first...and gotten the cancer out. At that time it was contained, but because of Pete's 16 PSA and Gleason 4 + 3 ..the opinions we got from Moffitt and also Shands in Gainesville, suggested that Brachy and Radiation would be the way to go, They thought it might have escaped the capsule... If you remember it was just after Rudy Guiliani had the Brachy and Radiation....in 2001.. We decided that we would do the same thing, because everyone was talking it up..
The cancer had not escaped yet, even though the PSA was high ..The radiation and brachy did not get it all ..OR, as one doctor said....it could have been a completely new cancer that came later to the prostate. If we had taken the prostate out....it never would have returned...But, see, that is all behind us, and we try not to look at that....The one thing we do talk about is the salvage part...Pete should have gone on HT right then instead of the salvage surgery....There are people who have been on HT for 18 years....our doctor told us.... But everyone is different and treatments that are not good for someone can be wonderful for another... Good luck to you....Diane
Posted 2/8/2009 12:26 AM (GMT 0)
Better assessment and knowledge leads to better choices and strategies to treat PCa, ok atleast in theory if you don't believe in that message. How many men got their slides reviewed and/or a 2nd or 3rd opinion on or on anything????
The value of a 2nd opinion should never be overlooked, but of course we all have that option of the whatever or darn the torpedos. Another thing about the value of a 2nd opinon, it shows the first opinion is not always correct and could be ruled either way in positive light or negative light (wouldn't you the patient like to have a better grasp of which is the truth and therefore the way), which for alot of patients changes the whole scenario or strategy on treatments, sometimes.
Posted 2/8/2009 3:45 AM (GMT 0)
Godfather,
My initial biopsy resulted in 4+3=7 with no perineural invasion seen, following a PSA of 3.9. Post surgery pathology was 4+4=8 with extensive perineural invasion. Later while investigating the desirability of follow up radiation I had all the slides looked at again by a very highly regarded pathology lab attached to a cancer clinic. Post surgery pathology was downgraded to the initial 4+3=7 with a point of focal extension comprised of grade 3 cells (although this extension was mentioned in the first surgery pathology, there was no mention of the extension's cell grade). I guess the answer is "it all depends on who's looking at it". Perineural invasion is very common and probably present in most PCa cases. There have been a couple of posts about it which have tended to dismiss its significance.
Bill
Posted 2/8/2009 12:50 PM (GMT 0)
Diane:

Thank you for taking the time to write and for being so candid. My wife Kathy and I are so sorry that you and Pete are having to go through this. You are in our thoughts and prayers.

Tony
Posted 2/8/2009 6:22 PM (GMT 0)
Stay positive, Tony,
I am a 4+3 brother, and it was a mess at surgery, but we knew that was likely given my high PSA. It doesn't matter right now, but rather get after it. You can do quite well...

peace,

Tony
Posted 2/8/2009 6:44 PM (GMT 0)
Hi Tony,

I also was sold on the robot and now think I made a real mistake. In my case the Dr. wasn't all that experienced but that is not what I am talking about.

It seems that it is routine with the robotic surgery to leave vas deferens, and seminal vessicles. With the possibility that your cancer is trying to get outside of the capsule I wonder that even in the hands of the best robotic guy you would not be better served by one of the best open anatomical guys who will take all of this other tissue and be able to touch and feel everything around the prostate.

Best wishes. Scott
Posted 2/8/2009 7:24 PM (GMT 0)
Scott, that was one of the selling points on me going with an open, was the ability to have more "parts" removed.
Posted 2/8/2009 7:59 PM (GMT 0)
Godfather,

Don't know if this helps or not but from Dr. Patrick Walsh's book:

Perineural invasion: a biopsy term meaning that prostate cancer has been found in the spaces around the nerves near the edge of the prostate. Because cancer that has penetrated the capsule can still be cured, perineural invasion has no long-term impact on a man's prognosis.

That sure sounded better to me. Hang in there.
Posted 2/8/2009 9:57 PM (GMT 0)

Tony, sorry to hear about the upgrade. The positive in this, using that term loosely, is that you are begining to get the full picture and once you have it all  you can formulate an attack plan. I like Tony from Vegas approach. Fire your torpedos now in the hopes of eradicating the demon. I pray all goes well for you my friend. Please keep us posted.

peace and love

dale

Posted 2/8/2009 11:01 PM (GMT 0)

gpg said...
Hi Tony,

.

It seems that it is routine with the robotic surgery to leave vas deferens, and seminal vessicles.

Best wishes. Scott

Scott,
I have never heard that before. It is my understanding that the seminal vesicles are always removed when undergoing prostatectomy as part of the procedure. There is no point to leaving them as they are virtually only a mixing chamber and there is nothing being produced to mix (other than the little tadpoles). The upper portion of the Vas Deferens are also removed as they are attached to the vesicles. The full length is obviously not removed as they go all the way to the testes.
Bill
Posted 2/9/2009 1:42 AM (GMT 0)

BillyMac said...

gpg said...
Hi Tony,

.

It seems that it is routine with the robotic surgery to leave vas deferens, and seminal vessicles.

Best wishes. Scott

Scott,
I have never heard that before. It is my understanding that the seminal vesicles are always removed when undergoing prostatectomy as part of the procedure. There is no point to leaving them as they are virtually only a mixing chamber and there is nothing being produced to mix (other than the little tadpoles). The upper portion of the Vas Deferens are also removed as they are attached to the vesicles. The full length is obviously not removed as they go all the way to the testes.
Bill

Yeah, go figure, no one told me either.  The robotic guys do not do the same surgery that the open retro guys do.  Scott

Posted 2/9/2009 1:51 AM (GMT 0)
Tony,
Is is never a good news when the Gleason score is upgraded. As you can see in my bio, mine is already as high as you can get without a perfect 10. I'm having Robotic surgery tomorrow to have this monster removed and won't rest until I get my biopsy report and future PSA results. All I can hope for is for the cancer to be contained. Good luck to you.
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