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Posted 8/29/2009 2:27 AM (GMT 0)
My pathology report states surgical margins benign, extraprostatic extension absent and seminal vesicle invasion absent, lymph nodes not involved, and bladder neck and apical margins negative for tumor.  The one negative aspect however was  perineural invasion present.  The cancer was 1.8cm and diagnosed as pT2c, was 4+5=9.

How concerned do I need to be about the perineural invasion considering the gleason 9 and what is prognosis?

Also, is 1.8 cm a large tumor?

The Old Sailor

Moderator modified to add a subject line ~ TC-LasVegas

Post Edited By Moderator (TC-LasVegas) : 8/31/2009 3:12:35 PM (GMT-6)

Posted 8/29/2009 2:42 AM (GMT 0)
Old Sailor,
1.8cm is a moderately large tumor. My doctor doesn't put a lot emphasis on perineural invasion; it's a way that PC cells can escape the capsule by following the nerve path; but doen't mean that it has. Perineural invasion is very common.
The latest protocols indicate that G9 PC needs a multimodal treatment to be more affective; this means an additional treatment like radiation or HT. You should ask your doctor about it.
JohnT
Posted 8/29/2009 2:49 AM (GMT 0)
Some pathologist have recomended to stop mentioning the perineural invasion, as it is very common but does not mean anything.
Posted 8/29/2009 3:28 AM (GMT 0)
JohnT and Geebra, I use to believe exactly what you two said about the perineural invasion, and also told the same by my uro/surgeon, but after meeting with 2 radiation oncologists (from the same practice), they both independently placed a different light on the subject, and they indicated that is exactly how PC cells escape from the prostate even with a clean post surgery pathology report. They said the nerves out are like giant open water pipes to stray pc cells. After listening to them, I am re-thinking my formal opinion on the subject.

David in SC
Posted 8/29/2009 3:56 AM (GMT 0)
Sailor,

Your pathology is pretty promising for a gleason 9.

While it is an agressive tumor grade, the size of the tumor isn't small but it isn't large either. Tumor size means more (experts say), when the volume ratio is higher. In other words, a 24 gram prostate with a 1.8 cm tumor is higher risk than a 42 gm prostate with the same size tumor. Right now, it's all about the pathology and yours came out on the sunny side of the microscope! Be well.

swim

Posted 8/29/2009 2:39 PM (GMT 0)
David, I understand that. But negative margins mean it has not happen yet. Isn't it right? Greg
Posted 8/29/2009 4:35 PM (GMT 0)
Greg,
Not exactly. With high grade tumors like G9s even though there is no evidence of extension there is a good chance that some PC cells have excaped into the blood stream without detection. This is why HT is recommended for those with a high PC gleason grade. You can wait until your PSA starts to rise, but if the margins were negative and the tumor was not next to the capsule a psa rise usually indicates that it is systemic not local.
JT
Posted 8/29/2009 5:39 PM (GMT 0)

My prostate was 38 gram so I guess the tumor being 1.8cm in average range.  I certainly hope that the good path report would have eliminated the cancer but I am fully aware that the high gleason grades of cancer usually require following up therapy. 

If adjuvant therapy is required, does that make prognosis significantly better?  Do gleason 6 & 7 cancers ever require follow up therapy? 

Does the primary pattern of grade 4 make any difference on prognosis?

What types of HT should I be looking at if we come to that point?

The Old Sailor

Posted 8/29/2009 6:16 PM (GMT 0)

Sailor,

G6 and 7 momotherapy usually works, if there is a progression, such as rising PSA then radiation or HT can be given depending on local or systemic reoccurrance. A grade 4 is still regarded as an agressive cancer prone to advance, a grade 5 is worse.

The common opinion is that immediate HT will increase the cure rate, but others say wait until psa starts to rise. The faster you start HT the better the progonosis. Usually it is ADT3, Lupron, Casodex and Proscar for 13 months; new recommendations favor 24 months. There are other protocols like DES, but I don't know much about those or their effectiveness.

The best advise is to get an opinion from a prostate oncologist, where do you live? I have a list of Oncologists by area if it would be useful. You may have to travel to see a good one, but any recommended treatments can be done locally. The specialist can follow your treatment progress by email or phone consults, so you can have the best doctor following your treatment without having to travel.

JohnT

Posted 8/29/2009 6:23 PM (GMT 0)

John T., thanks for info.  I live in Jacksonville, Florida and would appreciate the list of prostate oncologist in this area.

The Old Sailor

Posted 8/29/2009 6:48 PM (GMT 0)
Salior,

Maria Claudia Mallarino, Sarosota Fla. 941 377 9993; Uses Charles Myers protocol.

Dr Ron Wheeler, Sarosota Fla, 941 957 0007; He is a urologist; but more versed in advanced PC than most urologists.

good luck Old Sailor,
JT
Posted 8/29/2009 7:29 PM (GMT 0)
as a gleason 9 myself I have been watching this thread. I personally believe in taking evasive action as soon as possible. I did the ADT3 for 24 months and now I am taking a break (thank god) until Jan 15th. Well if my PSA is still zero I bet I get to wait longer.
thanks for all the sharing of information here, this is great stuff.

peace and joy
dale
Posted 8/29/2009 9:59 PM (GMT 0)
Liven,
You cannot compare your Gleason 9 to Sailors. Oh my...Sailor's is nowhere near so clearly advanced.

Sailor,
Albiet you have a good postoperative pathology report, getting a second opinion is a great idea. Then, see where that leads. There is no reason to be doing anything but monitor at this stage. Find a specialist and have his number handy just in case he's needed and request your surgeon send Jonathan Epstein at John's Hopkin's appropriate samples for second pathology opinion. In the mean time...relax a little bit. You have time to take your time.
Posted 8/29/2009 11:08 PM (GMT 0)

Swim, Liven, JT, I appreciate all the info.  I am probably getting ahead of myself and should sit back and relax a little as Swim suggests but I am a worrier and probably have myself buried already.

I was talking to a man involved with a prostate cancer support group and he said that I was very fortunate to have  a good path report from a 4+5 gleason, particulary the clean margins, clean lymph nodes, negative lymph node involvement and no extraprostatic extension.  He said he has talked to a lot of men who had far less favorable path reports than mine even though they had 3+3 gleason scores.

I do believe that by acting quickly after the saturation biopsy (5 weeks) for surgery, I may have made the right decision.

Also, I believe all my cancer was in the transition zone which I have read, usually has more favorable outcomes at surgery.  Have any of you heard this?

Thanks again, the Old Sailor 

Posted 8/29/2009 11:55 PM (GMT 0)
Sailor,

Transition zone tumors are more favorable for containment in that there is a lot of tissue between the tumor and the outside of the capsule. On the other hand transition zone tumors are usually G6 or G7 non agressive tumors. I would also talk to your surgeon and ask him if he got a good margin around the urethea, I doubt if this would be in the path report and it's the hardest part of getting good results with transition zone tumors. If there is any question about the urethea margin I would get radiation ASAP while it is still contained.
JohnT
Posted 8/29/2009 11:56 PM (GMT 0)
Sailor,

Transition zone tumors are more favorable for containment in that there is a lot of tissue between the tumor and the outside of the capsule. On the other hand transition zone tumors are usually G6 or G7 non agressive tumors. I would also talk to your surgeon and ask him if he got a good margin around the urethea, I doubt if this would be in the path report and it's the hardest part of getting good results with transition zone tumors. If there is any question about the urethea margin I would get radiation ASAP while it is still contained.
JohnT
Posted 8/30/2009 2:44 AM (GMT 0)
Old Sailor-that sounds like an excellent pathology report. Congratulations.
I have perineural invasion also and my surgeon dismissed it as something that shouldn't have even been reported upon.

I guess I don't really understand perineural invasion. Purgatorys response contains an understandable explanation of it, but I don't understand how that would then not be capsular penetration. Can anyone explain how that can be? Thanks.

Dave
Posted 8/30/2009 6:52 PM (GMT 0)
Capsular penetration is when the tumor extends out of the gland and into the capsule. This can be seen by scans or during surgery. Pereneurial invasion just says that there are nerves going through the tumor while the tumor is still contained in the gland.
Hope this explains it.
JT
Posted 8/30/2009 8:30 PM (GMT 0)
Dave, both my answer and JohnT's answers are correct to your question. The radiaton oncologist I spoke with, the 2nd one, said cancer cells like to take the path of least resistence, he said the nerves that penetrated the tumor, as John suggested above, are filled with hollow areas, making an easy escape path for cancer cells.

David in SC
Posted 8/30/2009 9:25 PM (GMT 0)
Thank you JohnT and Purgatory.  This is the first I've been able to comprehend the meaning of that term.  Now that I know what it means, I wonder why my surgeon (as well as other members surgeons) downplay the significance of it.  It seems significant.  I don't see that much written about it.

Thanks also to The Old Sailor for opening the discussion on this topic.

Dave

Posted 8/30/2009 9:31 PM (GMT 0)
Dave, most surgeons would typically say that, and even in Walsh's famous book "Surviving Prostate Cancer" the term is played down.
It just shows, and its often preached on this forumn, why a newly dx. person needs to get several opinions, not just from a surgeon, but also from radiation oncologists, and as JohnT will often state, even a prostate oncologist, though appearently there are too many of them to go around. A good radiation oncologist will have a different perspective on the technical merits of different kinds of cancers.

David in SC

PS Just for the record, after my 3rd and final biopsy a year ago this month, my uro/surgeon did not play down the significence of it, he said it concerned him in the biopsy report, since at that time, I was noted as being a Gleason 7 (4+3 pre surgery) with a PSA above 12.0 and climbing quickly.
Posted 8/31/2009 12:39 AM (GMT 0)
Glad I was able to open a discussion on the perineual invasion question although I still don't know how it fits in the overall scheme of things.

 

I have a couple new questions (1) how do you determine size of tumor (example, Dave in SC states his was 20%).  My prostate was 38 cm and size of tumor was 1.8 x 1.3 x 1.5 - how is this calculated.

 

(2) I am still having burning with urination at the end of the flow. Not as bad as Thursday when I had the catheter out but still very uncomfortable.  I am going to call my urologist at Mayo in the morning.  I am dribbling a little, but stay dry all night.  I'm doing my Kegels religiously and when can I hope to get some relief in that area.

 

(3) With the 4+5 gleason, most tables, charts etc. say that I probably had less than a 20% chance of clean margins,no lymph node or seminal vesicle involvement no bladder neck or apical margin involvement and no extraprostatic extension. Do you think there is a chance that pathologist could have graded the tumor too high and if so, does it make any difference at this point?

The Old Sailor

Posted 8/31/2009 1:03 AM (GMT 0)
Sailor,

Not sure about how tumor size was measured, I got the 20% right off my post surgery pathology report. Sure there are those here that would know how it's done.

The burning should honestly clear up in time and again, the med pyridium usually eliminates that discomfort and its cheap.

David
Posted 8/31/2009 3:33 AM (GMT 0)
I had my pathology slides re-read by MSK and their path report was different. They saw extraprostatic extention and two positive margins where Duke only saw one positive margin. The difference amounted to upgrade in staging from T2c to T3a. It is important to know, if there is a need for further treatment. In my case, as odd as it sounds, this upgrade was a good news. It raised probability of local recurrence. Knowing the results of your pathology are right is important. Many on this forum advocate a second opinion on the pathology from a well known experts, like the guy at Hopkins whose name escapes me. I hope you will not need this, but if you do you might want to have this info at your fingertips.
Posted 8/31/2009 4:30 AM (GMT 0)

I am always a bit concerned about 2nd opinions because unless both opinions are the same which one do you believe you normally believe the one that suits you best and not always the correct one

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