Pathology report today :( + :)=?

My husband's pathology report came in today.  He actually got it from one of the surgeons staff.  The doctor has not yet called to talk to us today.  We've been waiting patiently but it looks like office is closed now so maybe tomorrow.  So now I need my Band of Brothers and Sisters to help me figure it out...

Upgraded from a 3+4=7 to a 4+3=7

PT2C

12 lymph nodes tested=negative

Prostate 42 grams

Tumor dimension 3.0 x 1.8 cm

Proportion of prostatice tissue involved by tumor: 45%

Seminal vesicle invasion: not identified

Perineural invasion: not identified

Margins involved by invasive carcinoma: lateral left margin extensively involved by prostatic adenocarcinoma

So what do we do now?  I am shell shocked more than his inital diagnosis.  I guess I just hoped surgery would get the beast and life would be fine on the other side.  I guess I did not prepare myself for "what ifs" I think I do remember reading...now we need to get an oncologist on board....radiation...chemo...hormone therapy.  I guess I need to get out the prostate bible...surviving prostate cancer..and read those chapters that I mentally skipped:)  Please let me know what you think.

DGV
There are others here that could help you better than me, but it doesn't look too bad. He had a large tumor like I did, his Gleason was changed from 3+4=7 to 4+3=7 which is a little of a downer but the staging looks better than mine. Looks like the cancer was all in the prostate. I wouldn't worry too much right now.
My surgeon told me last week that I had a 1 in 5 chance for recurrence because my tumor was coming out of the prostate and may have left a cell that could develop later and cause the PSA to start rising.
The next couple of PSA tests will tell if they got it all so I wouldn't worry about radiation at this time.
That is one of the big benefits of surgery. If it comes back, we can still use radiation to kill the beast!

Bill

DGV,

Dag nab it even screwed up you signature in my reply, so sorry about that!!! I really do feel your anxiety!

Sorry to hear the disappointing path report. The extensive positive margins means there's most likely some adjuvant radiation needed, preceded by a few months of ADT, and continuing for a while afterwards. The lack of lymph node and seminal vesicle involvement are good signs that the cancer probably hasn't spread beyond the prostate bed where the radiation can get the rest. They will want to wait a few months for healing from the surgery. However, they will probably want to start the ADT immediately so that the freshly exposed cancer can be stopped before it can spread and take root.

Dame Goodeview,

When you have Terminex protect your house from termites what they do is surround your house with bait stations -- plastic cans in the ground with tasty bits of wood that termites can't resist. Every month they come out and look at those bits of wood to see which ones look chewed on and if your bait stations are OK then termites haven't made it into your house.

The reason they examine the seminal vesicles and the lymph nodes after they remove the prostate is that they act like bait stations. They are usually the first place the cancer will go once it escapes from the prostate and starts moving into other organs. The positive margin means that the cancer got out but since those "bait stations" are clean there is every chance that it hasn't gone very far yet and if you treat the area around where the prostate was you can still get it all.

I agree with Tall Allen: what your husband is looking at is adjuvant radiation (probably IMRT or IGRT) and neoadjuvant hormone therapy. In short, his treatments will be a lot like mine. They will probably start the hormones fairly soon but will wait a while for him to heal before they do the radiation (they like to do the radiation within 6 months of the prostatectomy, ideally somewhat sooner.) I didn't find the radiation bad but I must confess I am quite looking forward to the end of my hormones.

He'll do fine, by the way. It is all quite survivable. Keep us posted on what his doctors say.

DGV
You are going to hear from all sides of the fence. "X" is the standard, vs the "Y" people. Then the "Z" people show up and say everyone else is crazy. Do your homework, create a medical team that will treat you as a member, not as a patient. Get copies of all of your medical reports and start building a case file of your tests and treatments. Don't be rushed into anything. You have a long life ahead of you, enjoy it as you go down this path.

Hi DGV,

As the others have said, it does not look like the end of the world for your husband. Yes, he has a moderately aggressive cancer -- but the lymph nodes were all clear as were the seminal vesicles. That is a HUGE load of good news!

Probably the first post-op PSA test will determine if salvage radiation might be needed. With the positive margins and the G7, this IS a possibility in the future if not right away.

If his PSA is okay, then it will very possibly be a regular PSA test (perhaps every 3 months) to keep tracking it. If, in the future, the PSA begins to rise, then further treatment will probably be discussed by your doctor.

But, looking at the bottom line, he is probably going to be just fine even if further treatment proves to be necessary.

Take care,
Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1. PSA tests now annual.
Semi-firm erections now happening 14 months post-op & slowly getting a bit stronger.

D:
That is a lot of tumor with 45% involvement. The psa and margins and Gleason all support each other so nothing about this report stands out as an anomaly. Radiation might have been a good choice as first treatment so adjuvant or salvage RT is not at all improper to consider and plan for. Your man has a l-o-o-o-o-ong way to live. Many many years (if he takes care of himself).

DameGV - first off, as a "Yooper", I LOVE your quote from "Da Thirty Point Buck" - too bad we can't use 'Betty Lou' against this beast, eh?!?! That small bit of a sense of humor is good therapy right now - use that, and stay calm.

Lots of good advice here as always, and hopefully nobody is coming across as too pushy to you, but rather sharing what they went through which again is infinitely helpful.

No advice coming from me other than some thoughts: the no PNI / no SVI is great news, the beast seems to have been contained in the prostate bed = more good news, it sounds like your Dr is on top of this, and, if/when further treatment is needed there's lots of good arrows left in the quiver - even if we can't fire up Betty Lou!

My very best to you both - stay with us, and we'll be here with/for you!

I just wanted to echo Peter's advice to you to get a second opinion now, and not wait for the PSA measurements. Getting treated now is called "adjuvant" treatment, while waiting for the PSA to become detectable and/or rising is called "salvage" treatment. Recent studies have shown a significant survival advantage to adjuvant treatment over salvage treatment in cases like your husband's where significant amounts of cancer have been left in. You can read it for yourself in the following review:

Urol Oncol. 2009 Jan-Feb;27(1):87-8 said...

Post-radical prostatectomy management options for the positive surgical margin: argument for adjuvant radiotherapy.

Chin JL. Division of Surgical Oncology, University of Western Ontario, London, ON, Canada. [email protected]

The debate on the optimal management for patients with positive surgical margins following radical prostatectomy is on-going. From published evidence, we established that adjuvant XRT has acceptable, well-tolerated transient toxicity that dissipates with time. We examined the best conditions for optimal results from adjuvant radiotherapy (XRT), when the prostate-specific antigen (PSA) level is very low or undetectable, i.e., in the true adjuvant setting. We also examined the substantial amount of evidence from nonrandomized series, almost unanimously being in favor of early XRT. Most importantly, there is robust Level I evidence from well-executed randomized clinical trials reporting superior biochemical relapse-free and progression-free survival with early adjuvant XRT for patients with positive margins.

Surgeons know about surgery (we hope), and it would be unreasonable to expect that they would be expert in all facets of prostate cancer oncology. In this era of experts, we have to take the initiative in finding the right specialist for our specific case. I think you owe it to yourselves to seek out a urologic oncologist or a radiation oncologist, preferably one not referred by your surgeon.

Davidg,

I have a pretty strong pro-surgery bias (which I struggle with, from time to time) and I, mostly, don't see the anti-surgery bias in Allen's statements. There's nothing wrong with doctors being specialists. We tell people to look for a surgeon who has done thousands of operations. It's a bit much to also expect him to keep up on all the latest drug studies as well. He should know the everyday stuff and he should know his limits. The first thing my surgeon did when we got my Gleason 9 pathology report was to refer me to a medical oncologist and a radiation oncologist.

The reason I said "mostly" in the previous paragraph is the part about not trusting one's surgeon to recommend another specialist, especially after surgery when the surgeon has already had his shot at the goal and gotten his big paycheck. A good surgeon -- the kind one would trust to take out one's prostate -- has ongoing relations with oncologists and radiation guys who, after all, help keep the surgeon's problematic patients alive and make him look better.

Davidg, I don't think I'm prejudiced against surgeons. In your case, the surgeon was a urologic oncologist, so perhaps finding another specialist would be unnecessary. Most of the time, however, only specialists have the time and inclination to keep up with that particular field.

I am suspicious, however, of both surgeons and ROs who rush patients into treatments that are often unnecessary and expensive. There are "used car salesman" types among both, and excellent thoughtful doctors among both. Caveat emptor!

I do like an independent referral, however. On another board, there was a man who failed RP. He was referred to an RO in the same local practice who asked for an MRI and told the man there was nothing there, but that he needed 35 treatments of IMRT as salvage. Fortunately, the man went to a tertiary care center, UCSF, and showed them the MRI. The radiologist there told him that his surgeon had left a big piece of tissue behind and that they would only need to treat just that with 5 treatments of SBRT. Perhaps the first RO was trying to cover up the surgeon's mistake, or maybe it was his mistake in not seeing it? Hard to say. I do think there's peace of mind in choosing a second doctor or a consulting doctor who has no ties to the first one. I would feel comfortable, however, with a referral to a tertiary care center.

Wally - that's a good thing that no seminal vesicle invasion was identified. It means the pathologist could not find any cancer cells in the seminal vesicles.

Thanks again for the replies.  I have really learned a lot.  I will be getting some second opinions.  Clint goes in to get his cath out tomorrow here at out local uro's office.  We will be picking his brain.  The local oncologist here, we graduated from high school...weird to be seeing him for this..his office is getting records and we will be sitting down and talking to him soon, too.  Out ouf the blue the RO that we talked to in Utah when we were debating tx options, called Clint to see how he was doing.  Clint talked to him for awhile and gave him the update and he gave him his advice, too. I have a dumb question...when they say lateral left margin extensively involved...what do they mean as far as location.  I vision the tissue taken for review under the prostate in the left side of the prostate floor.  My husband visions it as the prostate gland itself's left side.