Post Surgery Results - Gleason 9 - Help!

Hello,

I wrote a couple months ago; asking for help if I should get the Radical Prostatectomy surgery or radiation/seeds/hormones. I decided on the surgery. Turns out my Gleason score was higher than I was originally told. I have the results from the biopsy and I am looking for help understanding what it all means.

I appreciate your help!

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Surgery Pathology Final Results - Radical Prostatectomy Specimen

Peripheral Zone Tumor: Yes to all (right mid/base, right apex, left mid/base, left apex, transitional zone tumor)

Extraprostatic Tumor Extension / Status of Extraprostatic Tissue:
Right & Left Posterolateral: Established
Right & Left Anterolateral: No

Margin Status:
Right & Left Posterolateral: No
Right & Left Anterolateral: No
Anterior: No
Distal Urethral Margin: Positive, focal.
Left Posterior: Positive, Linear extent 0.2 cm
Left Anterior: Positive, Linear extent 0.1 cm
Proximal Urethral Margin: No

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1. Prostate adenocarcinoma (2.3 cm). Gleason Grade: 4 + 5 = 9. Extensive right and left posterolateral extraprostatic extension. Seminal vesicles uninvolved. Left anterior and posterior distal urethral margin involved by tumor. Remaining margins free.

2. Anterior bladder neck margin, excision: Benign prostatic parenchyma, negative for malignancy.

3. Left pelvic lymph nodes, excision: Three benign lymph nodes, negative for malignancy (0/3).

4. Right pelvic lymph nodes, excision: One benign lymph node, negative for malignancy (0/1).

Gleason pattern 5 accounts for approximately 10-15% of the index nodule, with a smaller percentage of Gleason pattern 3 present.

Tumor Type: Acinar

Maximum dimension of largest tumor nodule: 2.3 cm

PT3a+ NO MX

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Size: 5x4.3x4 cm
Weight: 37.6g
Seinal Vesicles (length): right 3 cm / left - 1.8 cm
Vasa Deferentia (length): right 2 cm / left - 1.8 cm
Nodule: Multiple
Site of Nodule(s): both left and right
Description of Nodules: tan-white and indurated
Sliced Base to Apex, Number of Sections: 5
Tissue Procurement: No
Inked Margins Intact: Yes
PSA 7.5 at time of surgery

Post Edited (HiSunshineMI) : 2/18/2013 11:44:13 AM (GMT-7)

My Gleason going in was 3 + 4 = 7

I've already spoke with my surgeon and staff. I'm going for a follow up in a about a week. He said we would discuss radiation treatments at that point (was fairly certain that would be the case).

Looks a lot like my path report. I'm a 4+5 9.

Regardless, for now, concentrate on regaining continence, and being sure that you heal correctly. If they suggest RT (I suspect they will), you'll want to be in the best shape possible regarding recovery, but that will be somewhere in the range of at least 18 weeks out from your surgery.

Do your kegels, get out and walk often, and drink a lot of water to keep the bladder clean (even if it means you leak more right now).

Welcome back, sorry you have to be here.

Your post-op pathology looks quite familiar. It falls in the "definitely sucks but could be worse" category -- just like mine did. Like you, I was GS 7(3+4) going into surgery and GS 9(4+5) coming out. Like you, I had some positive margins but my seminal vesicles and lymph nodes were clear. And, like I expect you were, I had been hoping to get a look at prostate cancer in my rear view mirror and was not at all happy to find it still in my passenger seat.

That's the "definitely sucks" part. As for the "could be worse" part, I think you will find that there are a number of ways forward for you. I know you were hoping to be done with it -- I've been there and it is a crushing disappointment to get a pathology report like ours -- but there are treatments that give us good odds of beating the thing, even with our high-risk cancers. From now on your doctors will be cagey about using the word "cure" but that is what they will be reaching for, even if they will now call it a "durable remission."

I don't remember if you have consulted with a medical oncologist before but you should now. Probably your surgeon will recommend one. He may also refer you to a radiation oncologist; mine did; I saw them both the same day. There is a good chance that they will recommend additional "adjuvant" treatment(s) at this point to reduce the chances that your cancer will come back.

Doctors differ and theories vary but here is what my doctors recommended (and I did) when I was more-or-less where you are now:

1) I went on triple androgen blockade (Casodex, Lupron, Avodart) two weeks after I got the path report. (This keeps any potential remaining cancer inactive.)

2) I waited several months to allow the surgical area to heal and to regain as much continence as possible.

3) I had 37 sessions of adjuvant radiation threapy (ART) to my prostate bed and surrounding tissues. This should zap any remaining cancer that might have been missed.

4) I will be on the hormones for a total of two years. Several studies have shown that hormone therapy makes surgery and radiation treatments more effective.

If your doctors talk about similar things here are a couple of studies that they may talk about:

europepmc.org/articles/PMC3107759

www.nejm.org/doi/full/10.1056/NEJMoa0810095#t=abstract

And one of my old links in which I pretended to have stuff sorted out:

Does Adjuvant HT Kill Cancer Cells?

Good luck. Keep us posted.

Hey, you STILL have a shot at a cure....Welcome to the 50-50 club..If your PSA drops to undetectable, that buys some time..Get yourself recovered from the surgery before you start radiation..They may want to add HT to the radiation, seems it makes the radiation work better..How LONG they keep you on HT is open for negotiation..With G9, G10, you hit it as hard as you can with everything available..The newest LINACS do a better job in delivering the radiation, so try to be treated on best equipment possible by the best people possible..Best of luck to you...

Hisun:

Your pathology post surgery is an indicator of the status of your disease. This is way more significant that any biopsy results and eliminates the biopsy as any disease indicator.
No one has offered an explanation of the pathology so I will do so here in my amateur way.

Your tumor has spread outside of the prostate itself on both sides of the gland. This means the tumor has spread into the tissue and fatty material around the prostate itself, though this tissue was removed at surgery. This is an "extra-prostatic extension". This spread is considered extensive by the standards of pathology. You have positive margins in two locations. This means that the tumor had spread to the edge of the excised (removed) tissue. It is much more likely to be existing on the remaining tissue left in you after surgery.
The lymph nodes removed showed no cancer cells. Seminal vesicles showed no cancer cells. The tumor shows a majority of cells to be of Gleason 4 type with 15% Gleason 5 and a smaller amount of G 3.
The largest dimension of the prostate was 5 cm and the largest dimension of tumor was 2.3 cm, thus nearly half the prostate was tumor, by longest axis.
Your prostate was 37 grams which is in the normal range.

Now to my untrained eye this indicates a serious chance of tumor spread, though the most likely locations, SVI and nodes are clear, at least by microscopic inspection. This is where psa can be the most exquisitely sensitive indicator of treatment direction. And we should be pleased to have it. For now, Heal, sleep, relax. Healing requires sleep. There will be plenty of time enough to make decisions later.

You might try making an appointment at one of the large medical centers, such as Mayo Clinic. They have what is considered the largest prostate cancer database on Earth and they are one of the cutting edges of PC treatment.

If a trip there is feasible for you, it would not hurt to just visit them & get their opinions. Same could be said for Johns Hopkins, Cleveland Clinic, etc.

Good luck!
Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1.
Semi-firm erections now happening 14 months post-op & slowly getting a bit stronger.