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Second Opinion on Path Report More Serious?

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Posted 1/8/2014 2:34 PM (GMT 0)
Moffitt Cancer Center reviewed path report for second opinion. Original report said "suspicious for LVI." Moffitt is saying it's present. Everything else was identical. Gleason 4+3. The only thing that hasn't been positive are lymph nodes, but scans have not been done to date (thinking was that pre-op psa of 3.7 and clinical stage of T1c didn't necessitate them. MRI is being done in February but rad onc isn't expecting much with low psa). Rad Onc was wanting to start radiation end of March (surgery was Oct 31). Surgeon said don't do anything til rise in psa (he's Patel in Celebration, has done over 5000 surgeries so we assume he knows his stuff). Currently staged PT3B, post-op 6 week psa came back undetectable at 0.02 (which is a blessing). Now the confirmation on LVI. One step forward, two steps back. All current research says not a big game changer, but still not good. Had originally decided to hold off on radiation therapy until rise in psa. Now not so sure. Suggestions? Can you overtreat someone diagnosed like this? Still - never give up, never surrender.

-------------------------------------
* Pre-op psa 3.7, neg DRE, T1c (father had prostate cancer; died of pancreatic cancer)
* RRP 10/31/2013 (continence fine, ED still work in progress)
* Post-op path: 4+3=7, teriary 5 (both labs kept him as a 7)
* focal extraprostatic extension present
* Lymphovascular invasion present ("suspicious" from first lab, "present" from second lab)
* Bilateral seminal vesicles involved
* Tumor focally extended to apical resection margin (first lab said "anterior apical margin positive
," second lab said "extended to apical resection margin" - assume these are one in the same)
* Bilateral pelvic lymph nodes negative
Posted 1/8/2014 2:54 PM (GMT 0)
My PSA before surgery was similar to yours. I also had EPE but the margins wa negative. With a Gleason of (4+4) I was hesitant to do salvage radiation and my Uro suggested not to do it unless my PSA started to rise. I'm glad I did that because after 5 years I'm still in the zero club.
Posted 1/8/2014 3:18 PM (GMT 0)
When I don't know much about a topic I generally Google it so I can sound smarter than I am.

My 90 seconds of intensive research came up with a BJU meta-study that looked at LVI as an independent indicator. Heres the abstract:

Prognostic significance of lymphovascular invasion in radical prostatectomy specimens.

The abstract has a link to the full text (on the right side of the page).

Their conclusion: The existing literature is conflicting and of insufficient homogeneity to definitively establish LVI as an important independent prognostic factor of biochemical recurrence in prostate cancer prostatectomy specimens. Additional adequately powered studies are required to determine the clinical value of reports of LVI involvement. In the meantime, the use of LVI status as an independent prognostic factor for clinical prognostication and medical decision making is not recommended.

It would be more reassuring if they didn't base their negative recommendation on the available research being to scant and too messy, but there you go.

I must admit that I like the suggestions of your rad onc because with the 4+3 and a tertiary 5 I tend to worry about wait-and-see approaches. But I am aware that it is probably an unreasonable bias and I struggle with it.

Good luck. Keep us in the loop.
Posted 1/8/2014 4:09 PM (GMT 0)
Not much of a change in my view. Never heard of Moffit cancer center. Ask 2 different pairs of subjective eyes an opinion you are apt to get 2 different opinions. Ich mach nix on the LVI. Possibly they are noted for PCA treatment. I personally have never heard of them, but assume there pathologists are experienced.
I would wait for standard BCR using std psa test. I would wait until after .2 and 3 additional rises a month apart, before seeking tx.
Posted 1/8/2014 4:13 PM (GMT 0)
Personally I am more of the, "don't shoot till you see the whites of their eyes" kind of guy. I'd do a PSA retest in Feb. If it's still around 0.02, I'd hold off on radiation. If it's rising then fire away.

It's though when you've got differing medical opinions.

Just my non-medical thoughts.
Hang in there,
Andrew
Posted 1/8/2014 5:56 PM (GMT 0)
As I read the path report there are several unfavorable conditions mentioned, focal extension, LVI, and bilateral seminal vesicle invasion. If you are investigating salvage radiation, you have to consider the high probability of the disease being systemic and not local as seminal vesicle invasion correlates highly to a systemic condition.
Posted 1/8/2014 7:26 PM (GMT 0)
Just to add to JohnT's . Systemic would not be a favorable condition for radiation tx and I agree with that assessment. I just wasn't going to go there, as there is a chance they got it all with seminal vessels removal, possible -LVI , but yes If they did not get it all or why leaked out, based on postop path with a significant gl upgrade. 4+3+tertiary5= 9 regardless of what the lab reported. Check with the more advanced pathologists classification std. This is new Epstein started it and is begging to ne the standard.
IMO It hasn't recurred until it has recurred. .02 is not recurrence. This imo is where OT starts. waiting for a bone fide recurrence will not affect long term mortality IMO. IT IS NOT A GIVEN. Watch it and go on with your life. If it recurs, you will know it soon enough, to take action. Rush to treatment when there is something to treat. You don't want " the battle of Hue " taking place in side you.
Posted 1/9/2014 2:11 PM (GMT 0)
Thank you all for your responses. Consensus seems to be to "shoot when there's something to aim at." Google has become my constant companion (next to my husband). I read every journal, blog, article, comments, etc. that I can find (and make certain publish dates are current, not outdated). I've spoken with numerous oncologists, urologists, cancer centers. I've dissected my husband's pathology report down to the extra commas in the comments. We're sending path slides to Johns Hopkins for a third opinion (I knew there was a reason why we pay such high insurance premiums!). I understand metastatic, micrometastatic, and systemic, each of which sends chills down my spine. We've had medical opinions in all ranges regarding next steps post-surgery. Everything from RT alone, RT+ ADT 6 months, RT+ ADT 3 yrs, ADT alone, and watchful waiting til psa rises. I've read conflicting and inconclusive studies on adjuvent vs salvage treatment in both radiation and hormone therapies, LVI inclusiveness in path reporting, tertiary findings upgrading Gleason score, and so on. But the most reassuring information I have gotten is from each of you responding to my texts. You live it. Your experiences and knowledge are invaluable to us who are just starting this journey. I will never stop fighting for my husband's life. He will never stop, either. Success to each of you in your battles!
Posted 1/9/2014 3:23 PM (GMT 0)
mbock, you sound a lot like me.

I never thought I'd be a subscriber to "Uro Today."

The conflicting recommendations a conflicting studies make decisions difficult.
Posted 1/12/2014 10:25 PM (GMT 0)
Mbock
My situation is similar but worse due to Gleason 9. I'm pt3bN0 at path. I've been told by my Uro at Johns Hopkins that RT with SVI confers no benefit but ADT with RT has been shown to yield major increase in BCFS. I was .1 after RP and am waiting to see if PSA rises before doing anything.
Bob
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