Q&A on path report and possible secondary treatments

(Apologize for the "buffet" of questions, but thanks in advance for reading and replying, if possible...)

Had first post-LARP conference with surgeon last week. Got cath out, nurse removed a stitch from drainage incision, then met with doc for path report review. Ok, so feel free to hit me up side of head with Dr. Walsh's book for not asking more detailed questions of him--it was a hectic day--but I just heard the "organ-confined", no EPE, "happy days are here again", etc. I won't see him again until May 14, then again July 9 for the three month (with PSA test week before).

I asked for copy of path report before leaving, and now have questions maybe some of you guys can help with (please).

First, below is the gist of the report:

31g
4.5 x 3.6 x 3.5 cm
pT2c pN0 pMX


Primary Tumor (pT):

pT2: Organ confined
pT2c: Bilateral disease
"Note: subdivision of pT2 disease is problematic
and has not proven to be of prognostic significance" (what does this mean???)


Final Diagnosis:

adenocarcinoma, gleason 7 (3 + 4)
carcinoma is bilateral and in apex
right lateral margin focally positive
no extraprostatic extension of carcinoma identified
seminal vesicles negative for carcinoma
positive for perineural invasion
eight lymph nodes negative (four each side)

Tumor Quantitation: percentage of prostate involved by tumor: 30%


Microscopic Description:

"Carcinoma is identified bilaterally and in the apex. The right-sided tumor burden is much heavier than the left.
The right lateral resected margin is focally positive in two of the sections. The tumor goes up to the ink, but no definite extraprostatic tissue is invaded. The seminal vesicles and bladder margin sections are benign".


My questions (note, surgery was Apr 03, and my pre-op PSA test was 3.8). I know I may not get BCR, but may get it, so am just trying to gather info ahead of time:

(1) Do you have any general comments on the path report, good or bad?

(2) Isn't it odd that the path shows "up to the ink", but no EPE? How can that be? Is it likely the pathologist missed an EPE?

(3) Will the Han tables give an accurate guess, given my situation?

(4) I work in different state than surgery location. I will be arranging for my "every three month" PSAs with a local doc in my work state. Would it be out of line to also ask for PSA test for, say, first week of May, first week of June, and first week of July (week before my three month follow up with surgeon)? With PSA half-life 2-3 days, shouldn't my PSA be down to nil by early May, if it IS going to go down?

(5) I am wondering about the medical logic of waiting three months for a PSA test? Is it because even with pos margins, half of RP guys never get BCR, so why automatically put them *all* through secondary treatment with possible SEs? Ok, I get that, but is it safe for a G7 guy to wait once BCR has been identified?

(6) The surgeon is a urologist/oncologist. But I would probably have IMRT, if needed, in my work state, since I am running out of leave at job. If I see my PSA behaving badly in May/June, should I just go ahead and start arrangements for secondary treatment in my work state?

(7) Am not crazy about radiation treatments. My uncle with Pca had radiation--didn't go well--burned him badly--and he had miserable final years. Have a friend who did the LARP, got BCR, then just went for orchiectomy to "snuff out the fire". It has worked for him, with some accomodations for hot flashes, bone strengthening, etc. I hear the subcapsular orch. leaves a man less "disfigured". Is the orchiectomy route a possibility for me? (ED not a major concern any more for me).

(8) What is "castration resistant" (medical or hormonal) Pca? How would I know which type of Pca I have before deciding on a secondary treatment?

Your pathology report doesn't sound too bad. You had no EPE even though the cancer got close. Normally your first PSA test is done around 8 weeks, you don't need to wait 3 months. You should wait for the first result to see if any action is needed. If you don't get an undetectable PSA then you can have SRT since that could provide a cure. HT or castration do not offer a cure. Good luck.