Preparing for Salvage Radiation

I’m about 12 months into my journey. My quick history story. PSA 11.5 next- fusion biopsy. Gleason 9./
3 months later Prostatectomy. First PSA post surgery 0.023 6 weeks later 0.036 next-0.04. My urologist sends me to Radiation oncologist. PSMA ordered. No cancer detected. RO suggest sRT. So I’m starting 11/30. And I’m little nervous about it. Anyone gone down that similar path with suggestions. One concern I have is diet. I’m normally a high fiber diet. Lots of green veggies. But had trouble with first simulation because of gas. So any advice on diet would help. Having 39 sessions and 4 months ADT.

i HAVE TO ADD, why are they doing a PSMA PET? If your PSA is below .2, (not .02, .2, just to be clear), its doubtful if near impossible that the scan would pick up anything

The time on ADT seems very short, almost to the point that it seems hardly worth doing. Considering the G9, a minimum of a year of ADT seems more appropriate. But that's why the RO makes the big bucks and I don't.

Good luck with your treatment!

Thanks Mattam this I copied off my chart.
Final Pathologic Diagnosis

A. Right pelvic lymph nodes, dissection:
- No carcinoma identified in ten lymph nodes (0/10).

B. Left pelvic lymph nodes, dissection:
- No carcinoma identified in eleven lymph nodes (0/11).

C. Bladder neck margin, excision:
- Negative for carcinoma.

D. Prostate and seminal vesicles, prostatectomy:
- Prostatic adenocarcinoma, Gleason Score: 4 + 5 = 9 / 10 (Grade Group 5), with extraprostatic extension including involvement of the bilateral seminal vesicles (pT3b), see synoptic report.
Final Pathologic Diagnosis
Your Value

A. Right pelvic lymph nodes, dissection:
- No carcinoma identified in ten lymph nodes (0/10).

B. Left pelvic lymph nodes, dissection:
- No carcinoma identified in eleven lymph nodes (0/11).

C. Bladder neck margin, excision:
- Negative for carcinoma.

D. Prostate and seminal vesicles, prostatectomy:
- Prostatic adenocarcinoma, Gleason Score: 4 + 5 = 9 / 10 (Grade Group 5), with extraprostatic extension including involvement of the bilateral seminal vesicles (pT3b), see synoptic report.


Case seen by:
Hetal Mohanlal Gujaria, MD, MBBS – Pathology Resident
Travis L. Rice-Stitt, MD – Pathologist
Pathology, Oregon Health & Science University

My electronic signature indicates that I have personally reviewed all diagnostic slides, the gross and/or microscopic portion of this report and formulated the final diagnosis.
SYNOPTIC REPORTS
Your Value
PROSTATE GLAND: Radical Prostatectomy

PROSTATE GLAND: RADICAL PROSTATECTOMY - All Specimens

8th Edition - Protocol posted: 6/30/2021





SPECIMEN

Procedure: Radical prostatectomy

Prostate Size:

Prostate Weight (Grams): 26 g

Prostate Greatest Dimension (Centimeters): 4 cm

Additional Prostate Dimension (Centimeters): 3.5 cm

Additional Prostate Dimension (Centimeters): 3 cm



TUMOR

Histologic Type: Acinar adenocarcinoma

Histologic Grade:

Grade: Grade group 5 (Gleason Score 4 + 5 = 9)

Intraductal Carcinoma (IDC): Not identified

Cribriform Glands: Present

Treatment Effect: No known presurgical therapy

TUMOR QUANTITATION:

Estimated Percentage of Prostate Involved by Tumor: 31 - 40%

Extraprostatic Extension (EPE): Present, nonfocal

location of Extraprostatic Extension: Right anterior

location of Extraprostatic Extension: Right posterior

location of Extraprostatic Extension: Left anterior

location of Extraprostatic Extension: Left posterior

Urinary Bladder Neck Invasion: Not identified

Seminal Vesicle Invasion: Present, bilateral

Lymphovascular Invasion: Present

Perineural Invasion: Present



MARGINS

Margin Status: Invasive carcinoma present at margin

Linear Length of Margin(s) Involved by Carcinoma: Less than 3 mm (limited)

Focality of Margin Involvement: Unifocal

Margin(s) Involved by Invasive Carcinoma: Right apical



REGIONAL LYMPH NODES

Regional Lymph Node Status:

: All regional lymph nodes negative for tumor

Number of Lymph Nodes Examined: 21



PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition)

Reporting of pT, pN, and (when applicable) pM categories is based on information available to the pathologist at the time the report is issued. As per the AJCC (Chapter 1, 8th Ed.) it is the managing physician’s responsibility to establish the final pathologic stage based upon all pertinent information, including but potentially not limited to this pathology report.

Primary Tumor (pT): pT3b

pN Category: pN0
Gross Description
Your Value
A. Lymph node.
Received fresh labeled "right pelvic lymph nodes-1" are multiple tan-yellow, fatty and rubbery portions of soft tissue measuring 7.0 x 4.2 x 1.6 cm overall. Dissection yields 12 tan-yellow, fatty to tan-white and firm lymph node candidates ranging from 0.1 x 0.1 x 0.1 cm to 4.5 x 2.3 x 1.1 cm. The lymph node candidates are submitted entirely as follows:

A1, 6 lymph node candidates
A2, 2 lymph node candidates
A3, 1 lymph node candidate, bisected
A4, 1 lymph node candidate, serially sectioned
A5-A6, 1 lymph node candidate, serially sectioned
A7-A11, largest lymph node candidate, serially sectioned 4.5 x 2.3 x 1.1

HMG
B. Lymph node.
Received fresh labeled "left pelvic lymph nodes-2" are multiple tan-yellow, fatty and rubbery portions of soft tissue measuring 6.2 x 5.1 x 1.8 cm overall. Dissection yields 13 tan-yellow and fatty to tan-white and firm lymph node candidates ranging from 0.2 x 0.2 x 0.1 cm to 4.1 x 1.5 x 1.2 cm. The lymph node candidates are submitted entirely as follows:

B1, 6 lymph node candidates
B2, 4 lymph node candidates
B3, 1 lymph node candidate, bisected
B4-B5, 1 lymph node candidate, serially sectioned
B6-B10, largest lymph node candidate, serially sectioned

HMG
C. Bladder.
Received fresh labeled "bladder neck margin-3" is a 0.8 x 0.7 x 0.2 cm tan-brown, focally cauterized portion of soft tissue. The cauterized surfaces are inked black. The specimen is serially sectioned and submitted entirely in C1.

SLG: A-C

D. Prostate.
Received fresh labeled “prostate and seminal vesicles” is a 26 g prostate 3.0 centimeters apex to base x 4.0 cm transversely x 3.5 cm anterior to posterior cm), with attached seminal vesicles and vas deferens (right, 2.5 x 1.7 x 0.6 cm and left 3 x 2 x 0.6 cm). There is a 2.5 cm cm linear staple line on the anterior surface of the prostate. The specimen is inked according to the color scheme:
Staple line = red
Left side = blue
Right side = black

The prostate is serially sectioned from apex to base yielding 8 slices. A ill-defined dense gray-white lesion is identified in the predominantly left and right mid prostate within slices 3-8. Lesion is contained within the prostate but no extraprostatic extension.

The seminal vesicles/vas deferens are removed at the junction with the prostate and a full cross section of the tissue at the junction is submitted en face. The apex and base of the prostate are removed, halved, radially sectioned and entirely submitted. The remaining prostatic parenchyma is unremarkable. The prostate is submitted from apex (slice 1) to base (slice 8) entirely.

Post Edited (Taylor 1154) : 11/19/2022 12:52:36 PM (GMT-8)

If my own G9 (4+5) post-RP path report had included the adverse findings of:

– A 31-40% tumor burden
– Positive surgical margin
– Bilateral seminal vesicle invasion
– Multiple extraprostatic extensions
– Lymphovascular invasion and
– Cribriform glands

I would have immediately consulted with an RO to schedule my adjuvant therapy (RT+ADT).

Fortunately, I was a pT2 with negative margins. Out of curiosity about lymphovascular invasion, at one visit I asked my uro/surgeon if I had had LVI as my only adverse path finding along with my pT2 status, would he have recommended I have adjuvant therapy and, without missing a beat, he said Yes.

Djin

Taylor 1154,

I had a small positive margin resulting in two years after the prostatectomy my PSA hit 0.2 ng/ml so I had IMRT/IGRT (39 sessions at 1.8 grays each) salvage radiation 7 years ago. I too was worried about diet, urinary, and GI issues during the radiation treatment. My RO told me not to worry, don't change anything in my diet and if an issue does occur then we will deal with it.

I didn't change anything in my diet or routine. I had zero side effects, no urinary, no GI, and no noticeable fatigue during and after the treatment. I wake up at 4:30 am every morning drive 35 minutes to work, and on the way home at 2:30 pm, I would stop by the hospital's radiation unit for my treatment. Usually in and out in less than 15 minutes. The only requirement was to have a fairly full bladder during treatment; I would drink a bottle of water about 20 minutes before arriving for treatment.

After the final session, I had an exit consult with the RO, and I asked him if the radiation was turned on because I didn't feel or have any symptoms from radiation. He laughed and said it was on.

The bottom line is don't worry. Everything will go smoothly.

PS. I eat a fairly low-fat diet, but I do drink 10 to 12 cups of french roast coffee and enjoy a glass of wine in the evening.

Post Edited (lapilot) : 11/20/2022 8:58:07 AM (GMT-8)

As far as side effects from adjuvant radiation at 5 mos post-op, there were a couple:
Developed itchy rash in pubic area about a week into treatments which is not a common side effect per techs but it happens. Used cream a couple times per day and it went away after a short while.
Developed some urgency towards the end of treatments so had to pay attention to restrooms when out and about. Resolved shortly after treatments stopped.
Significant tiredness began towards the end of treatment and for a few weeks after treatment. Had a couple of days where I was pretty pooped and took a good nap. Went away within a month.
No bladder or bowel issues other than the noted urgency. My techs were pretty hard core about full bladder and empty colon which we would discuss at every treatment as I would always ask if they did not mention. They were harder in the first few weeks trying to get my attention I think.
Basically, a major time waster for 5 minute treatments. The last week takes forever….

Rick's 6-month of ADT with his SRT for his pT3a G7 (3+4) seems to me in line with SOC. During your 4 months of ADT, I would do more research and get additional consults as to whether this is too short a duration given your pT3b G9 (4+5) with many adverse findings.

You might also inquire at your consults whether a Decipher test on your RP tissue would be of help in establishing the ideal ADT duration based on your risk (low, intermediate, or high) of encountering metastases within 5 years.

Djin

Thanks Rick 1
For the comment. I hope your doing well and continue do so. It’s been an up down emotional 12 months getting to where I’m at. Glad to have found this web site. Encouraging comments goes a long way. I will be back with an update.