Welcome New Member Sister111 Who Has a Question

There is clinical (cT), pathological (pT) staging and and AJCC staging (capital Roman numbers and letters). They are somewhat independent but overlap. It's very confusing. (Men who have RT as their primary treatment have only a clinical staging.)

The two more recent changes to TNM staging that I know of were (1) pT2 is no longer subdivided into pT2a, pT2b, pT3c acording to tumor location in the lobes, because this is now known to have no bearing on prognosis, and (2) bladder neck invasion is now pT3a rather than pT4 because its prognosis doesn't warrant the more serious staging.

So yes, if there is spread to local lymph nodes, it is Stage IV, but to me the AJCC staging has less information than the pathological staging, which, coupled with a whole-prostate Gleason score and PSA history, gives a more complete picture of the cancer. The chart that Mumbo linked shows the relationships between the different types of staging. Note that Stage IV can have any T staging:

"IVA - The tumor might or might not be growing into tissues near the prostate [any T] . The cancer has spread to nearby lymph nodes [N1] but has not spread elsewhere in the body [M0]. The Grade Group can be any value, and the PSA can be any value.

IVB - The cancer might or might not be growing into tissues near the prostate [any T] and might or might not have spread to nearby lymph nodes [any N]. It has spread to other parts of the body, such as distant lymph nodes, bones, or other organs [M1]. The Grade Group can be any value, and the PSA can be any value."

I don't see AJCC staging referred to much on forums, but usually cT and pT staging. Stage IV seems to be used mainly for cases of advanced metastatic disease when diagnosed. In the case of the OP's brother, it sounds strange to say it was Stage IV cancer that may have been cured by surgery shortly after it was diagnosed.

Djin

Mumbo, you may find some answers to your questions in the paper I linked on page 1 of this thread. The paper also gives you an idea why PCa spread to only one or a couple of pelvic lymph node(s) is a tricky issue as far as adjuvant vs. salvage treatment, and if adjuvant, what adjuvant treatment. For someone whose tumor was (otherwise) prostate confined on surgery, it is tempting to wait and follow the PSA trend -- if, say, only 1 in 16 nodes was positive, you can make a case that the sole metastasis was removed and adjuvant therapy would be over-treatment, especially if you are talking about RT + ADT. The extent of the metastasis may have been malignant cells traveling only a short distance to a sentinel lymph node(s) very near the prostate (the sentinel node of an organ is the most likely to harbor a metastasis). As the paper linked states, some men are cured with the surgery. If I were in this boat, I'd certainly appreciate a very detailed and careful analysis of my pathology when making a post-op treatment decision. Just saying I'm Stage IV A doesn't really fit all situations.

Let's see what the OP's docs say -- I have a feeling they will want to see the post-op PSA, and I wouldn't be surprised if one option offered is to hold off on adjuvant treatment and follow the PSA, which may or may not lead to adjuvant or salvage therapy.

Djin

Post Edited (DjinTonic) : 12/20/2020 12:52:48 PM (GMT-7)

I want to thank all of you for all of the great information, advice and support you have given me. I will definitely be taking your advice and get a second opinion on my brother’s pathology report from Dr. Epstein. Also, I will suggest that my brother get the genomic testing to determine risk level for the metastasis in next 5 years. My fear is that this will show high risk due to I had another brother who died from pancreatic cancer 12 years ago at the age of 48.

Thank you all so much.

I wish all of you good health.

Thank you all for your kindness, suggestions and advice. I just went with my brother to his first urologist oncologist follow up appointment since the RP surgery a month ago. He stated there were 2 things he didn’t like on the pathology report. First was the EPE although he said he went wider to achieve negative margins. Second there was 1 small left pelvic lymph node that metastasized. (He removed 11 lymph nodes. Only 1 metastasized).

Doctor said that the probability that other metastasized lymph nodes remain in his body is 70-80%. He thinks it is still local and highly doubts it spread to distant areas.

Doctor said if there were 2 or more metastasized lymph nodes he would send my brother immediately to get radiation and 2 years of hormone therapy. Because only 1 lymph node metastasized he said to wait on radiation and hormone therapy until a future PSA is greater than zero.

Concerned about the 80% probability that cancer is still remains I asked if we have the option of radiation/hormone therapy now even if the next PSA is zero. He said yes but prefers to do a PSA in 4 weeks then PSAs every 3 months and wait for a result above 0. I expressed my concern that if we wait until the PSA rises, will the cancer spread to distant areas. He said no. He said the PSA is very sensitive and should rise before going distant. I’m still nervous about this. I’ve research this for hours and I’m very concerned that by waiting the cancer might spread.

I would appreciate all of your thoughts on what you would do or advise. If the psa is 0 on the next test (feb 4) would you do radiation and 2 years hormone therapy or wait for the psa to rise.

Also my brother is worried about the effects on the body from the 2 year hormone therapy. He is 66 years old, not overweight, good health and exercises 3 days a week. What are your thoughts on how hard this is on the body?

Hi Sister. Here are my thoughts.

The dilemma, as you know, is that on one hand his cancer did metastasize, there may be remaining nodes that are be positive, and, coupled with the EPE, point to the advisability of adjuvant treatment after a period of healing to allow the recovery of continence and potency. On the other hand, as the paper I linked above points out, it is possible that the RP removed all the cancer, in which case further treatment would be overtreatment.

I would have your brother's post-op PSA trend followed by a 2- or 3-decimal PSA test, known as ultrasensitive PSA (uPSA). No PSA test will come back "zero", but, rather, at the lowest, "undetectable", which means below that test's lower limit of detection. By using a uPSA test that comes back at an "undetectable" level of, say, <0.02, you can wait to see if his PSA does indeed rise, but still start treatment at a point at or below below a threshold of 0.1. A more sensitive test lets you (1) know the actual PSA with more precision and certainty, (b) better track the post-op trend, and (3) perhaps give you some idea of the rate of rise if his PSA starts to climb.

If you follow his PSA with the "standard" test used for men with prostates, "undetectable" is <0.1 and you'll have no more information unless and until his PSA reaches 0.1 or higher. In other words, this give you little lead time and no real info about his PSA trend.

I am not surprised your doc advised waiting. My advice would be to meet with at least one radiation oncologist who specializes in PCa treatment for another opinion, which may agree. As far as waiting, RT will remain effective on pelvic metastases, and ADT will still be effective on distant metastases. However, there is no harm in making plans. And, of course, those plans can change if you so desire. I think the discussion with your docs will focus on what relatively low PSA level to use as the point to trigger any further therapy. His current PSA and any rate of rise may also figure intothe timing of further treatment

BTW, what was the final Gleason score in the post-RP pathology report?

Djin

I agree that the best use of this time is to start researching radiation oncologists in the event that you'll need one. Also, it couldn't hurt to get the ROs perspective on your brother's case as well.

As to ADT, I did 18 months. It's a slog, but it's also tolerable. I felt somewhat creaky and older than I actually was. Having no libido is weird. (Although a bit liberating as well.) The fact that your brother already exercises will help him--the best thing you can do is stay active and work to maintain muscle mass. It's actually like staying home during covid--it's not fun, but I can suck it up for the greater good. Ditto for ADT.