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follow up to yesterday's thread wrt G6 PC

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Posted 9/28/2011 1:47 PM (GMT 0)

When discussing the results of my saturation biopsy with my uro on 9/22,

he indicated that the cancer was confined to the prostate, stage T1C.

On Monday,9/26 my medical oncologist at Dana Farber was not definitive-

indicating that the tables showed a probability of 80% or so that it was

confined to the prostate.

This was quite unsettling as my PC was G6 and seemingly detected "early".

It never entered my mind that the cancer could be outside the gland at

this time.

Also, when a stage of T1C is assigned it seems like it is someone's best

educated guess-or, is there reason to believe it is 100% accurate?

Again, I would appreciate any feedback from others on the above.

Thx, bachez

Posted 9/28/2011 1:50 PM (GMT 0)
As you will or have already found out, when dealing with PCa there is no such thing as 100% probabilities on anything. This is IMO the CYA for docs. The only 100% is that if you have RP surgery you have a 100% probability that you no longer have a prostate.

TWG

Posted 9/28/2011 1:58 PM (GMT 0)
Even with a saturation biopsy, I was of the opinion that confinement to the prostate cannot be determined with certainty until the organ is examined thoroughly and biopsied after it is removed surgically. Before that, I've always assumed that organ confinement is an educated guess. I guess I would want to ask my uro how he can be sure the cancer is organ contained. Maybe all the cancer was found deep in the core of the gland.

I certainly seem to remember guys posting here...G6 guys.....who are found to have EPE and/or positive margins.

That's why I get an uneasy feeling when G6 guys are told they "have nothing to worry about."

The more I read here, the more it seems that nothing can ever be taken for granted when it comes to prostate cancer.

8 out of 10 odds for confinement are good, and they say G6 cancer has a tough time spreading even if it escapes the capsule, but your oncologist may well be accurate in his assessment. I'm no expert and not a doctor, but these are my thoughts.
Posted 9/28/2011 2:04 PM (GMT 0)

As I understand, the only definitive way to stage is with a post surgery pathology.   You have a clinical staging and is an estimate.   The urologist doing the DRE explains what he feels, but that varies by doctor and a good amount of the prostate can not be felt very well by the DRE.   The biopsy is of the prostate and can't 100% conclude that everything is still within the gland.   Even with a saturation biopsy, most of the gland is not checked.   The Partin tables and other nomograms are statisticlly generated probabilities based on actual cases over long periods of time.  They are probability indicators and are not definitive.

In combination, these tools help to give you a good idea of what you have, but are not 100% conclusive.   Often, after surgical pathology, stages and Gleason scores can be changed for the better or the worse.  An 80% probability is rather high but not high enough on its own to conclusively rule out spread.

Have each of the doctors detail their findings and also run your own charts using the tools available at Memorial Sloan Kettering, Johns Hopkins, Bostwick Labs, and other places that allow you to use the predictive tools.   This information will be vital to help you make treatment decisions.

If there is significant enough probability of escape or positive margins, radiation treatment with brachytherapy and external beam is usually preferred over surgery as the effectiveness is the same, but side effects are less.   I suggest you now consult brachytherapy specialists to learn of all your treatment options.   Now is the time to do all your homework as it appears that you may be low risk and have time on your side.

Recently at a major conference a prostate specialist reported that he once gave a person a DRE because of rising PSA after surgery only to find an intact prostate!   So not even surgey can 100% conclude that there is no longer a prostate.  Admittedly this is a fringe case, but points out what another person said that there are very few absolutes.

Posted 9/28/2011 2:22 PM (GMT 0)
I've seen a lot of posts where members comment about their staging moving from T1 or T2 up to T3 and T4 after surgery, as if the doctor had made an error.

In Scardino's book, he makes the point that pre-surgery staging can only be based on what is felt with a DRE or seen on a scan.

Posted 9/28/2011 2:52 PM (GMT 0)
Water Guy, even your 100% certainty of having your prostate removed by surgery isn't really 100%. We had a guy here a couple of years ago, also from SC, that a surgeon blotched the surgery on this poor guy, and left behind almost 40% of his prostate, and then tried to cover up his error by rushing the guy into RT. He no longer posts here, but he was in the middle of some serious litigation at the time.
Posted 9/28/2011 2:53 PM (GMT 0)
Before dx my GP and uro felt nothing odd during a DRE.
The biopsy found only 2 positive cores out of 12 Gleason 6.
The post surgery pathology however was much worse: Gleason (3+4) and the cancer had spread to the seminal vesicles and the bladder neck. So I suddenly went up to T3. Nobody made a mistake, the Gleason 6 was the best they could do before the op with the "tools" available.
The problem was that nearly all the cancer was along the top of the gland so the biopsy missed most of it and the DRE fingers couldn't reach the area affected.

I think it would help guys and uros if we/they had a better idea of where the cancer was. This requires imaging with the latest techniques so that suspect areas show up on a scan and the biopsies can be taken from those areas.

It also stands to reason that if the first bit of cancer that appears is near the edge of the gland then you have more chance of it going beyond the edge, even if it is non aggressive, whereas if it starts growing in the middle if could stay organ confined even if it was agressive.

Alf
Posted 9/28/2011 2:57 PM (GMT 0)
Purgatory,

How did the doc leave 40% of the prostate behind?  So I stand corrected even having a RP isn't 100% that the prostate is gone only 99.99% smilewinkgrin

Posted 9/28/2011 3:05 PM (GMT 0)
Hey Water Guy,

To follow up on what Purgatory said, I have a friend who had his prostate removed. Two years later his PSA began to invcease and he was being scheduled for salavage radiation.

Based on a second opinion from doctors at the University of Colorado, it was concluded that his rise in PSA was likely due to prostate tissue that was left behind.

For the last two years he has been taking Avodart and the PSA has stayed down.
Posted 9/28/2011 9:16 PM (GMT 0)
I for one am beginning to wonder about bachez's saturation biopsy. There are saturation biopsies and Saturation biopsies. For some reason bachez won't tell us how many cores were taken. In my case I had 45 for a 28g gland. I've heard as many as 90 down to 28.
Posted 9/28/2011 11:20 PM (GMT 0)
Although I know what RCS is saying, I'm not sure what constitutes prostate tissue. If you have a rise in PSA after surgery then this typically means that at least one PCa cell is still in the body somewhere. So doesn't this mean that a rise in post surgery PSA will always mean prostate tissue has been left behind.

Does a PCa cell(s) equate to prostate tissue? Where else can a rise in PSA come from if not from prostate tissue remaining in the body?

I'm thinking way to much today!!! Food for thought.
Posted 9/28/2011 11:50 PM (GMT 0)
Ziggy-forgot to respond to your question earlier. Not a case of withholding info.

If I am reading the path report correctly, appears to be 13 cores, so maybe it was less than a saturation biopsy.

bachez
Posted 9/29/2011 11:49 AM (GMT 0)
I understand that it is nearly impossible to confirm that all the prostate gland is removed, so some cells could remain behind. If any of the cancer is out of the gland in micro mets, the surgeon can not see them and if they are outside the margins the pathologists will not see them.

The cancer cells usually give off significantly more PSA than the normal prostate cells until the cancer cells mutate to the point they can no longer be identified as being from the prostate and then give off little or no PSA.

A rise in PSA after surgery wuld normally indicate there is still cancer somewhere that the surgeon couldn't remove. If there is detectible PSA after surgery, but no rise, it could indicate there is still some prostate tissue left but no cancer. That is why it is the rise in PSA that causes concern. With radiation patients, there will normally be some healthy cells that are not killed, thus the expectation that there will be some PSA. So long as it is stable over time, it would indicate the cancer was killed. That is why the threshold for PSA that many rad-oncs use for maintenance is 0.20 PSA. The large clinic here in Atlanta that was a brachytherapy pioneer uses this metric to indicate a cure/remission.
Posted 9/29/2011 2:39 PM (GMT 0)

bachez said...
Ziggy-forgot to respond to your question earlier. Not a case of withholding info.

If I am reading the path report correctly, appears to be 13 cores, so maybe it was less than a saturation biopsy.

bachez

No it was not a saturation biopsy. It appears to have been a standard 12 core transrectal biopsy. Far less precise than a saturation biopsy that has many many more cores and is done through the perineum. That changes everything with more cancer being more likely present now than if it had actually been a saturation biopsy.
Posted 9/29/2011 5:04 PM (GMT 0)
Clinical staging, the staging from a biopsy, always has a certain degree of risk. This is why those having surgery based on clinical low risk stats have only an 85% chance of cure. Post op, or pathological staging, that shows a confined tumor after removal have a 99% chance of cure with surgery. The difference between the 85% and 99% is the risk that the cancer has penetrated the capsule, is around the nerves that were not removed in neve sparing operations or that some of the postate tissue that has PC was left behind.
The difference in results of clinically staged low risk PC between surgery (85%) and Brachy or radiation, (90% to 95%) is the result of the above factors as radiation will hit those areas that are sometimes missed with surgery. So as the doctor told you there is a 15% to 20% chance that even when clinical staging indicates a confined tumor there is a chance that it is not confined or will be cured by surgical removal. As has been stated many times on this board, there is no 100% garantee when dealing with PC, but the odds are definately on your side and any treatment you choose will have a very good probability of being successful.
JohnT
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