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*UPDATE w/full pathology report* 2nd Post Op PSA is RISING!

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Posted 3/29/2014 5:10 PM (GMT 0)
Absolutely agree with you tarhoosier! I'd run from that urologist!

As bad (to me) as my biopsy report was at diagnosis, my urologist said "worse case, we can get you 10 to 15 years more of quality life". Then went on to say "I don't think we have to worry about a worse case situation". That was said prior to my surgery last September.
I think he was pointing out that I am now 65, which would make me 75-80 ("worse case"); a reasonably good long life regardless.
Posted 3/29/2014 8:18 PM (GMT 0)
Thanks BillyBob...I saw iSpark's numbers and was comforted by them. What a ride for him that must've been.

Yeah, I think my uro has some contempt for me because I asked him a lot of really difficult questions that I think he took personal. The comment after I was just handed a paper showing I was Dx'ed with PCa of "See, we weren't just trying to steal your money." reeked of retribution and revenge. I told him prior to my biopsy I just didn't want a biopsy because it was an expensive test to run that benefited him. I wanted to know he was truly doing it out of real concern for my health. I wasn't rude about it but I was very direct. I apologized for coming on that way but I had to know.

It's pretty clear to me that I need a new Uro and will do just that. I may be moving to the state where I had my surgery here in a few days.

Thank you all for the comments. I'm not overly concerned. You hate to see any PSA score anywhere near .1 but I read extensively on the subject last night and some labs are brutal when it comes to properly calibrating equipment. I could literally already be over .1 or under my initial 0.06 and never know it. There are all kinds of assays and they can vary as much as 20-30%. Those are wild swings and can really play with your head. I'm not an ostrich with my head in the sand, either. I realize my undetectable is a little less undetectable than most but as I read last night reading beneath .300 is difficult. The stuff I read last night said not to be concerned to .3...not .2 and that I really didn't need to act until I got to 1.0. I realize the .2 threshold that is accepted...however, there are many other opinions. One persons reality based on what they've been told can totally conflict with another's. My reality will be a very liberal approach to my numbers, if I even get them going forward.
Posted 3/29/2014 9:01 PM (GMT 0)
Here is the rationale for SRT before PSA reaches .2:

The Timing of Salvage Radiotherapy After Radical Prostatectomy: A Systematic Review

Dr. King's meta-analysis of 41 studies and 5597 adjuvant and salvage RT patients is widely accepted. By waiting for the PSA to increase from .2 to .3, one stands to lose 2.6% in recurrence-free survival. That's an average based on many men who had higher risk features than yours - your results may differ. But there is little to lose by waiting until you have a confirmed PSA of .2, especially given your low risk features.

Because your path report shows pGS6, no positive margins, EPE or SVI, the most likely scenario is that your surgeon left some tissue behind. Perhaps the surgeon's report will confirm that. Perhaps that will show up on an MRI, which would be necessary anyway if you decide to get SRT. The good news is that neoadjuvant/concurrent/adjuvant ADT would be unnecessary, which would reduce your risks of lasting SEs. Also, it's good that you seem to be nearly healed from the surgery by now.
Posted 3/29/2014 9:15 PM (GMT 0)
Here's my pathology report, in full...

08/29/2013 Surgical Pathology
Page 1 of 3
(CR13-5991)
Requested By:
4-6507
SLIDE DISPOSITION:
DIAGNOSIS:
A. Lymph nodes, right pelvic, dissection: Multiple (6) lymph nodes
are negative for tumor.
B. Lymph nodes, left pelvic, dissection: Multiple (7) lymph nodes
are negative for tumor.
C. Prostate, apical resection: Fibromuscular tissue and benign
prostatic tissue.
D. Prostate, radical resection: Adenocarcinoma, acinar type.
Synoptic Report.
See
Synoptic Report:
Specimen Procedure: Radical prostatectomy.
Lymph Node Sampling: Right pelvic lymph nodes. Left pelvic lymph
nodes.
Histologic Type: Acinar adenocarcinoma.
Histologic Pattern (Gleason Pattern):
Primary: Grade 3
Secondary: Grade 3
Total: 6
Tertiary Pattern: Not present.
Tumor Size and location: Single tumor 0.2 x 0.1 x 0.1 cm right mid
posterior.
Periprostatic Soft Tissue Involvement: Absent.
Seminal Vesicles:
Left: Not involved.
Right: Not involved.
Treatment Effect: Not present.
Margins: Negative for tumor.
Lymphovascular Invasion: Not identified.
Pathologic Staging (AJCC, 7th edition):
Primary tumor: pT2
Regional lymph nodes: pN0
Number submitted (total): 13
Number involved (total): 0
Distant Metastasis: Not applicable.
Prostate Size: 40.0 gram, 3.3 (S-I) x 4.4 (A-P) x 4.2 cm.
The synoptic report incorporates information from all relevant
surgical material and includes all required data elements of the
current CAP Cancer Protocol.
Participated in interpretation:

9/3/2013 16:21 Interpreted by:
Report electronically signed by
Transcribed by: 8/29/2013 17:26:50
PRELIMINARY FROZEN SECTION CONSULTATION:
This printout was generated through Patient Online Services and was the most current version as of the date and time generated.
Patient Copy

C. Prostate, apical resection:
prostatic tissue.
Page 2 of 3
Fibromuscular tissue and benign
Frozen section histologic interpretation performed by:
GROSS DEscriptION:
A. Received: fresh labeled "right pelvic lymph nodes"
Specimen: lymphatic and adipose tissue
Size: 6.0 x 5.0 x 2.6 cm, aggregate
Submitted: lymph nodes, perms
Grossed by:
EMX
B. Received: fresh labeled "left pelvic lymph nodes"
Specimen: lymphatic and adipose tissue
Size: 6.3 x 4.5 x 1.4 cm, aggregate
Submitted: lymph nodes, perms
Grossed by:
RCR
C. Received fresh labeled "prostate, apical resection" is a 0.7 x
0.5 x 0.3 cm fragment of tan-pink soft tissue. All submitted.
Grossed by EMX.
D. Received: fresh labeled "prostate"
Prostatectomy: radical
Prostate: 40.0 gram, 3.3 (S-I) x 4.4 (A-P) x 4.2 cm
Mass: unifocal, 2.1 x 1.5 x 0.3 cm
Mass Site: right mid posterior, left mid posterior
Submitted: Inked, prostatic apex and base margins perpendicular,
representative, perms
Grossed by: MHH/EMX
BLOCK SUMMARY:
Part A: Right
1 Rt pelvic
2 Rt pelvic
3 Rt pelvic
4 Rt pelvic
5 Rt pelvic
6 Rt pelvic
7 Rt pelvic
Part
1
2
3
4
5
B:
Lt
Lt
Lt
Lt
Lt
pelvic lymph node(s)
LNs 4(A1)
LNs 1of2(A2)
LNs 2of2(A2)
LNs 1of2(A3)
LNs 2of2(A3)
LNs 1of2(A4)
LNs 2of2(A4)
Left Pelvic Lymph Nodes
pelvic LN-1(B1)
pelvic LN-1(B2)
pelvic LNs-3(B3)
pelvic LN-1(B4)
pelvic LN-1(B5)
Part C: Prostate, apical resection
1 Prostate, apical resection
Part D: Prostate
1 Rt anterior apex margin
2 Rt posterior apex margin
3 Rt bladder base margin
4 Lt anterior apex margin
5 Lt posterior apex margin
6 Lt bladder base margin
7 Rt posterior inferior
8 Rt mid posterior
9 Rt mid anterior
10 Rt posterior superior
11 Rt seminal vesicle-1
12 Rt seminal vesicle-2
13 Lt posterior inferior
14 Lt mid posterior
15
16
17
18
Lt
Lt
Lt
Lt
Page 3 of 3
mid anterior
posterior superior
seminal vesicle-1
seminal vesicle-2
Posted 3/29/2014 9:17 PM (GMT 0)
I meant your surgeon's report - not your path report. He's supposed to write up everything that happened during the surgery.
Posted 3/29/2014 9:22 PM (GMT 0)

Tall Allen said...
I meant your surgeon's report - not your path report. He's supposed to write up everything that happened during the surgery.

LOL! Sorry, Tall. I have access to many things through Mayo's online patient services. Not sure that's out there for me to look at online.

It's probably best I communicate with Mayo in some form considering they did my surgery. I'm hoping to have them available to me shortly.

EDIT: I just went back out to my online patient services and found no surgeon's notes section.

Post Edited (Inchoation) : 3/29/2014 3:41:58 PM (GMT-6)

Posted 3/30/2014 12:09 AM (GMT 0)
Op Notes, or operation notes is the transcription of all that is discussed during the OR procedure, in your case a prostatectomy. It exists, though you may need to request it. I asked for mine and read it in the uro office. There was nothing in mine that surprised me. I was reading for general education and not for a certain specific issue. It exists. It must.
Posted 3/30/2014 12:18 AM (GMT 0)
My surgery report was short and filled with "standard" this and "accepted procedure" that. Did not at all reflect (to me) the extra work, since it all fell into standard descriptions and phrases. I found it of no great revelation.

I got a copy when I requested all the hospital files (from the hospital directly) that Aflac required.
Posted 3/30/2014 5:29 AM (GMT 0)
Mine gave a detailed description of the operation. The most interesting to me was the nerve sparing. I loved his phrase of gently teasing the nerve bundle away from the prostate, especially as it was an open surgery. I can see, even with gently teasing, how the bundle can be traumatized so as to prolong healing, to the point with me, that it took 2 years to achieve a working erection and this, and as we speak, only with viagra. side note, one side nerve bundle was disected in a wide cut to insure negative margin . As it turned out the cancer was well within the capsule, not the wrapping, but the present itself , to borrow Walshes terminology. BTW, Walsh thought, is that nature gives us a spare, indicating one will do the trick. That I do not buy, though as Purgatory says and proves . we are all different. I mean 2 is better than 1 in most things , ceptin tumors or any negative data points, negative in the since of Negative in its nasty sense,i.e not negative margins which is positive. Darn, there, go those darn quantum particles just a swapping and a poppin roles again. tee hee.
Posted 3/30/2014 12:21 PM (GMT 0)

Inchoation said...
I finally got the results I just had to have.

Now, I'm not so sure it's the news I wanted to hear.

My 1st Post Op PSA was 0.06...there was an issue of whether that included a < (less than) in front of it. If I was less than 0.06 then the trend isn't good.

My 2nd Post Op PSA was 0.082. Yikes. :-) I was assured this was "normal" by the person giving the result. However, I read a study recently posted, here, that people who have post op PSA nadir's of over 0.04 are at an 89% risk of biochemical recurrence.

I don't think that a second PSA reading of 0.082 is great at all. However what you do have going for you is the G6, it is very hard for G6 prostate cancer to live outside the prostate. Also some surgeons do leave a fair bit of tissue behind - perhaps your surgeon did too. Wish you the best.

An
Posted 3/30/2014 2:28 PM (GMT 0)
I don't either, An! Not enthused by this but most of this journey has left me on pins and needles regarding what "might happen". It drives, and is a good thing for me, me deep into my faith where I belong and don't always go without troubling news.

0.082 will only be what it is in the context of the next couple tests.
Posted 3/30/2014 3:19 PM (GMT 0)
Inchoation,

I agree with An38. Your classification of Gleason 6 is your best hope.

 See Do adenocarcinomas of the prostate with Gleason score (GS) ≤6 have the potential to metastasize to lymph nodes? (http://www.ncbi.nlm.nih.gov/pubmed/22531173)

 

In particular, this article found that

 Of over 14,000 totally embedded radical prostatectomies from multiple institutions, there was not a single case of a GS ≤6 tumor with LN metastases.

 

 

Posted 3/30/2014 4:59 PM (GMT 0)
Thank you, Turp... I thought about that study you posted but didn't recall the exact specifics. That is very comforting to me. It is so strange to really get into the nuts and bolts of this because it can drive you nuts and make you want to bolt.

It all depends what study you want to hang your hat on. What is of interest to me is that fact I was initially a G7, but downgraded. So, I guess there is some question as to what my real Gleason is/was. If I truly was more a 7 than 6, there is more reason for concern. Hearing I was G6 at pathology was of huge relief when pondering what my PSA's may say going forward. Should I be worried about metastasis? No. It appears to be next to impossible. However, that doesn't mean it can't return locally. Perhaps, if I have a change of heart, which I don't foresee, I could take localized radiation as it would be pretty much a certainty that's where the cancer is. I don't know much about adjunct therapies, but I wonder if there if HiFu, or a different type therapy could be used as salvage so to speak? I'm opposed to radiation. We'll see how opposed I am to it should I get to a point that I'm told it's my only hope. I have a different set of beliefs so will cling to them. I believe faith is critical to my personal wellness.
Posted 3/30/2014 5:08 PM (GMT 0)
inchoation,

the G6 at pathology is more reliable for two reasons:

1. the post operative pathology checks out the entire prostate, not just a small sample

2. I assume when they checked the postoperative pathology, they knew that the needle biopsy had G7: I would think they would be extra-careful

If you have doubts about the G6, you can ask for a second opinion from Epstein at JHU.

Posted 3/30/2014 5:22 PM (GMT 0)
Incho, your point on local spread is a good one, tho it is true 6 cells do have a problem out side of the womb, but it is not impossible and they can spread to rectum and/or bladder. That one is my problem with a name change for a 6, including a variant of 6 that does destroy good cells.Since you seem to be ruling out SRT, You really need to somehow curb the anxiety level, as you have a long life ahead of you. You certainly don't want Pca to be the center of your life. " Accent the positive, eliminate the negative, and, {importantly},don't mess with Mr. in-between. He's the real bummer.
Posted 3/30/2014 6:09 PM (GMT 0)

logoslidat said...
Incho, your point on local spread is a good one, tho it is true 6 cells do have a problem out side of the womb, but it is not impossible and they can spread to rectum and/or bladder. That one is my problem with a name change for a 6, including a variant of 6 that does destroy good cells.Since you seem to be ruling out SRT, You really need to somehow curb the anxiety level, as you have a long life ahead of you. You certainly don't want Pca to be the center of your life. " Accent the positive, eliminate the negative, and, {importantly},don't mess with Mr. in-between. He's the real bummer.

LOL. Yes, he is a bummer. I have to balance my intelligence with my faith often. I love to learn and I love faith. One has to carry more weight and most of the time it is faith, but not always. My goal is to make faith the #1 carrier of me for the rest of my days. In doing that, I will do nothing but open up all kinds of good things for me and others.
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