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Posted 9/5/2012 10:53 PM (GMT 0)
I've been lurking on this list for more than a year and I am extremely (!!!) grateful for all the information and encouragement that I find here. I had surgery May 2011 followed by seven weeks of radiation three months later. I have a couple of questions that I haven't seen discussed . . . altho maybe I just haven't searched enough.

I'm t3b with positive SVI, positive margins, and my Gleason is 3+4 with tertiary 5.

Question 1: What is the significance of the tertiary 5 on the overall sense of how things will go from here?

Question 2: Does the surgery and/or the radiation normally affect testosterone levels?

Again, I am so appreciative of all the information that I have found here and I sincerely wish you all the best

Ivolgin
Posted 9/6/2012 2:51 AM (GMT 0)
Sorry in delay in answering this. Here are my opinions:
1. Tertiary 5 simply means that there are more undifferentiated cells than someone who did not have tertiary five. As you have had both surgery and adjuvant radiation (a wise choice with T3b), if your psa is undetectable at present, it means frequent monitoring.
2. I do not believe radiation or surgery decrease testosterone, as testosterone production is in the testes and adrenal glands, not the prostate.
Good luck
Posted 9/6/2012 5:24 AM (GMT 0)
The Grade 5 cells are very aggressive so you can expect your treatment to be aggressive too..As for "T" levels, have you had it checked? The treatment should have little effect but I have noticed MANY men with PC also have low testosterone levels..The two seem to go together..
Posted 9/6/2012 6:05 AM (GMT 0)
This study sheds some light on your first question:
www.ncbi.nlm.nih.gov/pubmed/21933333

While nothing is certain, this study suggests that someone with Gleason 3+4, who also has some cells with pattern 5 as a tertiary pattern, has a lower probability of remaining recurrence-free than a person with Gleason 3+4 but no tertiary pattern 5. Thus, frequent monitoring and more aggressive treatment is called for.

"a TGG pattern 5 was a statistically significant predictor of clinical failure when adjusting for pathological stage, surgical margin status, extraprostatic extension and seminal vesicle invasion" The phrase "clinical failure" was defined to mean either local recurrence in the prostate bed or distant metastases within a period of about 9 years followup, on average. This was not a particularly large study (only 148 cases.)

An earlier study looked at all the research to date and came to a similar overall conclusions:
www.ncbi.nlm.nih.gov/pubmed/17466898 This type of study is called "meta-analysis"

Post Edited (proscapt) : 9/6/2012 12:08:47 AM (GMT-6)

Posted 9/6/2012 2:37 PM (GMT 0)
Thank you. This is very helpful. As always, this forum is so useful for the circulation of information.

All the best to you!
Posted 9/6/2012 3:41 PM (GMT 0)
Since you got your answers, all I can do is say Welcome to the Forum and what took ya so long to uncloak? devil Glad you did decide to come out of the shadows, thanks for sharing, stick around in the light now. tongue
Posted 10/5/2012 7:00 PM (GMT 0)
Glad to find this thread.

RP in 3/12 went really well.

Cancer was totally confined to the prostate. pGS of 4+3
Yesterday, however, I noticed that on my path report a tertiary GS of 5 was noted and of course I was alarmed.

My question: Does the Tertiary 5 GS have prognostic value, with regard to PSA Recurrence, independent of the other pathological characteristics? Do these studies show tertiary 5 patients with an increased risk of PSA recurrence just because of the tertiary 5, or is it that they have an increased risk due to a higher likelihood of negative pathological characteristics ( ie EPE, positive margins, SV invasion, lymph node invvolvement).

In other words, from these studies, should someone with my path report consider himself at a higher risk because of the tertiary 5 or is it irrelevant, because I have already confirmed a totally organ confined disease?
Posted 10/5/2012 9:54 PM (GMT 0)
RH,

It would be best to start a new thread asking these questions.

However, since we're here, I'll put in my 2 cents.

- My uro believes any G5 at all is a total game-change, and you treat it aggressively.

- We all wish that when they say "organ confined" that there was a way to prove it. We discover that when we die of something else first.

Posted 10/5/2012 10:08 PM (GMT 0)
First of all lurk all you want lurkers , there is zero, I mean zero shame in that unless someone wants to start a thread on it, and instill shame in this fine forum. We got enough troubles, Sez I…... I got 4+3 tertiary 5. It would be better with out, , but there are plenty here have tertiary something that is not include in Path report. that is a recent thing in the ever present fine tuning of a disease, that is constantly changing or at least appears to be.. Its the same nasty dis ease its always been ceptin, we are getting more savvy to it , and thats a good thing…..
Posted 10/5/2012 11:41 PM (GMT 0)
Sorry..didn't mean to hijack the thread, thought my input was related to the original post and felt I would further the discussion.

Thanks for the reply.

When I mean 'confirmed organ confined' I mean no EPE, based on the pathologist report. Surely that can be confirmed. Maybe I'm misunderstanding something, but my understanding is that the cancer either spreads from growing through the prostate's capsule (EPE)into the SV, lymph nodes and beyond, or it spreads from micro metastasis.

I guess my question is whether or not these studies indicate that a Tertiary 5 means an increased risk of micro mets after EPE was ruled out, or do they simply indicate that a Tertiary 5 increases one's risk of EPE in the first place and therefore a subsequent increased risk of recurrence because of the EPE.

Also, when you say treat aggressively, what does that mean after RP? Are you talking about radiation? Even after EPE is ruled out?
Posted 10/6/2012 12:23 AM (GMT 0)
RH,

No foul, just that folks may read the first post in a thread then decide they aren't interested, so your question, although similar, falls through the cracks.

Micro mets are the usual suspect - my uro had already suggested pre-surgery that with the PNI found in my biopsy, spread must be presumed, but with the hope the micro mets would remain micro for years. Not so in my case.

I could not say what studies say about tertiary G5, as I lost interest in that detail when it was secondary for me. I've asked my uro since in our conversations. He said that as far as he was concerned, any G5 at all was a game-changer. He would have had me do HT from the start, but my job circumstances would not have allowed it.

But with my case, there really was no escape from RT after surgery.

I don't have any basis to say that G5 increases the risk of EPE. That seems a factor of how early the PCa is discovered. EPE and PNI are two ways for the cancer to escape, not related as I understand it. Finding G5 means that it may have been G5 that escaped.

Mind you that I am the eternal pessimist. That which did not kill me today did not make me stronger, it will just be back later.

devil  

Posted 10/6/2012 12:47 AM (GMT 0)
Thanks..
I must say I'm glad for this forum..it is priceless.
Posted 10/6/2012 4:18 AM (GMT 0)
When your surgical post op pathology says the there is no EPE, that means based on the knowledge, science, that is available today the cells stayed in your prostate, based on the pathology expertise today. You will always have negative margins with this Pathology. You can also have EPE and have negative margins. this is accomplished, by cutting wide outside the capsule. Having said this, this does not mean a stray cell or 2,3,or more may have escaped any time prior to surgery. A number of folks here think this can be thru PNI. I am not one of them, but could be convinced. there is no doubt in my mind and most surgeons Im sure, they they can get out undetected. A Gl 6 will arguably die outside the "womb , so to speak. But a 4 and particularly a 5, being more aggressive can survive and set up shop outside locally and spread, or thru a process called angiogenesis { google} can metastasize to other organs,etc I have great/good pathology, but Extensive PNI and upgrade in gleason plus foci tertiary 5 is concerning, for reason's stated above. Bottom line, neg margins, capsulcontained is better than not but does not mean that your body is free of cancer, If it was you would need no follow up psa test. Hope that helps. Read Walshes book on margins, epe etc.
Posted 10/6/2012 11:49 AM (GMT 0)
Thanks logos,

I have read Dr. Walsh's book, but didn't see anything mentioned of Tertiary 5. I thought it might be something that has become more common since The book's publication. And I have read up on angiogenesis, very interesting stuff...I watched a TED talk about it which was great.

I see your point about the possibility of micromets (the escape of cancer on a cellular level even without EPE) and that's exactly what I am concerned about of course. In reading many of these studies regarding the significance of Tertiary 5, almost all of them say that a Tert 5 is indicative of a higher risk of PSA recurrence, but none of them, as far as I can see, distinguish between a higher risk because of a probable EPE as opposed to a higher risk of micromets (cellular spread without EPE). It is concerning to hear it said that a GS of 7 with Tert 5 should be treated aggressively post op as if it were a GS8..treated aggressively as in RT!

I had no sign of PNI, so I'm hopeful that the Tert 5 cells remained inside the capsule of the prostate.

Neither my local Uro nor my surgeon (at Johns Hopkins) even mentioned the Tert 5, so for the most part, I'm counting on their knowledge of the subject. I'm assuming that if they felt I should be concerned about it, they would have mentioned it, especially if it would make a difference with regard to treatment post op.

Boy, I really have hijacked this thread..apologies to Ivo. Thanks for the replies.
Posted 10/6/2012 3:12 PM (GMT 0)
I think I understand your point now. IMO It is considered significant from some experts,and studies, because of the possible cellular escape, NOT in an epe, but from other sources as discussed. Postop Pathology did not see any EPE. By definition EPE is, don't think Im on a limb here, arguably what the Pathology reveals after the gland has been sliced in diced. PNI is considered clinically significant in a preop biopsy because it could be a precursor of epe. Once the gland is on the table and no epe is found its significance is gone. Though there is a school of thought that it is still significant , post biopsy,as a source of cell leakage. Again I am not in that school. Imean you can toss this thing around all day and all nite and never get the answer or you can get second opinions till you get the answer you want. Once you get a few years of undetectables, you may or may not, relax a bit. I have. It really is the half empty/half full outlook. BTW you are not " born this way' You have a free will to determine how you react to lifes blows. No one keeps the flesh forever, thankfully……..
Posted 10/6/2012 3:21 PM (GMT 0)
There is a subtle or maybe not so subtle implication from last post about second opinions. I totally believe in 2nd opinions and some times it is not the one you would like but the one that could save your life. My basic belief is, if possible, try to live your life, in spite of the blows. Obviously this becomes more difficult in the end game, which we all will experience. Cynicism is a temptation, we all endure at times.
Posted 10/7/2012 12:45 PM (GMT 0)
No need to apologize for hijacking the thread! You've generated more discussion about tertiary 5 and that's just what I wanted. As a t3b with positive margins etc. I am very curious about all this.

Thanks
Posted 10/7/2012 11:03 PM (GMT 0)
I've done a bit more reading on this and found that the push to include notes about tertiary grades in biopsy and pathology reports largely come from the 2005 International Society of Urological Pathology Consensus Statement on Gleason Grading of Prostate Cancer.

Found here..
www.siapecpiemonte.it/download/isup_2005.pdf

Basically, it is recommended that in a needle biopsy, the overall GS should be derived by adding the primary GS (most common pattern) to the highest GS (i.e. if there is 3+4 GS with Tert 5, the overall GS should be 8, rather than 7, and if there is a GS of 4+3 with a Tert 5, then the overall GS should be reported as 9 rather than a 7).

But this is just for needle biopsies..
The recommendation for Tert 5 in a pathology report is different. It says...

"In radical prostatectomy specimens, the situation is not analogous to that seen on needle biopsy, as one has the entire nodule available for examination. For example, tumors at radical prostatectomy that are Gleason score 4 + 3 = 7 with a tertiary pattern 5, whereas behaving worse than Gleason score 4 + 3 = 7 tumors without a tertiary pattern 5 have a much lower
incidence of seminal vesicle invasion and lymph node metastases compared with tumors that are Gleason score 4 + 5 = 9. Consequently, on radical prostatectomy specimens, it would be misleading to derive the Gleason score by adding the most common Gleason pattern and the highest Gleason pattern. It was the consensus of the group that for a radical prostatectomy specimen one assigns the Gleason score based on the primary and secondary patterns with a comment as to the tertiary pattern".
Posted 10/8/2012 12:30 AM (GMT 0)
I suppose that the vagueness of the conclusion -- that post-op path reports should include a comment if tertiary 5 is found -- suggests that it may be significant but that the significance has not been clearly established.

This isn't my first cancer and, while I realize they are only numbers, I keep trying to figure out my odds of recurrence. I guess that the statistical clarity I want just isn't possible.

Thanks for looking into all this.
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