need opinons- restaged to T3a on path

Hi- first - thank you to all of you who post here, as I have read many of your posts over the past year and have found them to be very helpful throughout this process.  After several years of a relatively low but elevated PSA, and a negative biopsy in 2008, my dad was found to have adenocarcinoma on a repeat biopsy in March 2012 (only 1/18 positive, right middle apex, Gleason 3+3=6), PSA was between 4 and 6 throughout that time. Highest PSA 6.25, April 2012.  We thought it was essentially T0/T1.  He is 67 years old, and otherwise in amazing health. Very functional, still working, etc. He decided to have robotic (DaVinci) prostatectomy (at Duke), Nov 2012. Intraoperative report was good with negative margins reported, so the surgeon spared the nerves.  Unfortunately the postop path showed tumor was much larger than thought, and in a position that the biosy can't access well(anterior). Margins, extraprostatic extension were positive . Restaged to  T3aN0MXR1 . Gleason 4+3=7. All nodes, bladder, etc negative.  Perinerual invasion positive . (will paste details below) We go for repeat PSA shortly, and meanwhile have seen a radiation oncologist to consider pre-emptive radiation to the prostate bed. I think he is leaning towards this, as opposed to future salvage radiation.  I have read the NCCN guidelines and discussed with the radiologist the advantages of early vs. salvage radiation, understanding the modest advantages of reduced recurrence, potential survival benefit vs. possible side effects. (gee, they really downplay the side effects but we are still concerned about these). But we will see what that PSA says and go from there.  He is doing really well after the surgery with only an occasional small leak on exertion. No incontinence at night. They haven't done a bone scan, nor recommended we see a medical oncologist up to this point. I am wondering what others in this situation have done, and if you considered the addition of androgen deprivation (hormone) therapy? It's not listed in the guidelines as recommended at this point, given that he had the prostatectomy, and I think the side effects may be unappealing. Also, is there anything else we should be considering that we haven't yet? would really appreciate some opinions... --------------------------------------------------------------------- MRI March 2012 Peripheral Zone: Appears normal. Patient's known prostate adenocarcinoma within the medial right apex is not definitely visualized. ----------------- Biopsy March 2012: Only 1/18 positive RIGHT MIDDLE APEX PROSTATIC ADENOCARCINOMA, GLEASON PATTERN 3 + 3 = 6. CARCINOMA INVOLVES 1 MM OF AGGREGATE BIOPSY LENGTH 15 MM. -------------------- Pathology from Nov 2012: pT3aN0MXR1 prostate 49 grams Tumor features: - Histologic type: ADENOCARCINOMA - Gleason grade: - Primary 4 - Secondary: 3 - Sum: 7 - Tertiary Gleason? PRESENT - Tertiary grade: 5 - Percent: 20% - Anterior dominant? POSITIVE - Index tumor location? LEFT AND RIGHT, APEX-MID, ANTERIOR - Size 3.0 x 2.5 x 1.2 CM - Index feature(s) MAIN TUMOR MASS Tumor quantity: - Laterality BILATERAL - Right side volume: 15 % - Left side volume: 15 % - Overall volume: 15 %   Extraprostatic extension: - Apex muscle: NEGATIVE - Bladder neck muscle: NEGATIVE - Periphery: - Right apical: POSITIVE, ESTABLISHED, ANTERIOR - Right mid: POSITIVE, ESTABLISHED, ANTERIOR - Right basal: NEGATIVE - Left apical: POSITIVE, ESTABLISHED, ANTERIOR - Left mid: POSITIVE, ESTABLISHED, ANTERIOR - Left basal: NEGATIVE - Right seminal vesicle: NEGATIVE - Left seminal vesicle: NEGATIVE   Margins: - Apex: NEGATIVE - Bladder neck: NEGATIVE - Periphery: - Right apical: POSITIVE, >25 MM, ANTERIOR - Right mid: POSITIVE, >25 MM, ANTERIOR - Right basal: NEGATIVE - Left apical: POSITIVE, >25 MM, ANTERIOR - Left mid: POSITIVE, >25 MM, ANTERIOR - Left basal: NEGATIVE - Right seminal vesicle: NEGATIVE - Left seminal vesicle: NEGATIVE   Accessory: - Lymphvascular invasion: EQUIVOCAL - Perineural invasion: POSITIVE - Treatment effect: NOT APPLICABLE Additional findings: NODULAR HYPERPLASIA Regional lymph nodes: ELEVEN LYMPH NODE PROFILES, NEGATIVE FOR MALIGNANCY (0/11)      

Welcome to the forum (and to your dad)

I too had an upgrade (from 3+3 to 3+4) and it also turned out that I had tumour outside the gland in the seminal vesicles.

The initial response was that while this weas not a good developement it would be best to wait for a post op PSA test too as they didn;t like to do additional things like Radiation until it was clear there had been a recurrence - it was still be possible that they had nonetheless managed to remove all the nasty stuff.

My first post-op PSA was 0.1, so we agreed to just carry on watching the PSA
My second PSA after surgery however was 0.4, and that left them and me ijn no doubnt that there was soemthing still there, and that something needed to be done, so it was only then that I went to see a radiation doc. The uro's reception made the appointment as soon as I stopped talking to the uro and I saw someone a few says later.
So I had Salvage RT, a few weeks later and after that my PSA did go down and it has also stayed down.

So I think wait and see is probably okay, but also it will help to find out plenty about SRT (and ART too)

All the best, and good luck with that PSA test.

Alf

Lily,
Your dad's path report looks very similar to mine, see my status below. I was worried that there may be some cancer left. Your dad's prostate was about the same size as mine also so it was a large tumor.
I would not panic yet. Relax and let the future PSA test show what is happening before you plan for radiation. There will be plenty of time for that.
My first 2 reports were <0.1 undetectable. Celebrate the successful surgery now and wait to see what happens down the road.

Good luck to you all and keep us informed.

Bill

Lily, I'l give you my opinion based on what I have learned the past 5 years since starting this journey myself - if I had the results your dad has, I would watchfully wait until the PSA is at or above 0.2 before initiating SRT. I have a friend that had positive margins and has increasing PSA after the surgery, and he is determined to not have SRT. In his case, his PSA doubling rate is between 18 months and 2 years, with no indication that he will need to do anything to address it for a good long time.

One thing to note regarding starting the radiation soon: some patients do not see further continence recovery past the point that they start radiation, so it can be important to make sure that the incontinence has had a good chance to improve acceptably first.

I wish you and your dad well in this battle.
Jeff

That's a good PSA reading. Enjoy that news.

Here's hoping it stays low.
Andrew