2nd Opinion - Post Surgery

Hello,

I had radical prostatectomy (going in I was Gleason 7, PSA 7.5). The pathology upgraded me to a Gleason 4+5=9. I was back in to get my PSA tested a week ago, and it is at .02.

Looking for advice on next steps. My surgeon gave me a referral to the radiation oncologist at University of Michigan (where I had my surgery). Should I be getting more opinions? How do I know who to go to? I'd like to stay in Michigan for my treatment, but at the same time want the "best" recommendation on how to move forward.

I tried the second opinion route at John Hopkins (you don't have to physically be there) but they won't allow it for residents of Michigan.

Thoughts? What would you do?

Thanks!

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

-------------
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

-------------

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

Ah! I posted it wrong. It was <0.1 post surgery. I'll work on my signature now...

Age 62 (marathon runner)
Diagnosed 11/2013
PT3a+ NO MX
----PROCEDURES---
1/13 Radical Prostatectomy
----PSA---
1/13 PSA 7.5 (Pre Surgery)
3/13 PSA < 0.1 (Post Surgery)
----POST OP PATH---
Gleason updated from 7 to 9 (4+5=9)
Prostate adenocarcinoma (2.3 cm)
Left Posterior: Positive, Linear extent 0.2 cm
Left Anterior: Positive, Linear extent 0.1 cm
Seminal Vesicle: Not Involved
Lymphnodes: Not Invo

I'm confused about your margins. Did you originally say that there were positive margins observed in the pathology? The last reference to your pathology did NOT indicate positive margins. I might be looking at it wrong, but hopefully there were NO positive margins.

With a post-op PSA of 0.02, you are at undetectable (zero) status, which is where you want to be. So, as Purgatory asked, what indication have you been given that you might need additional treatment?

Even with an upgrade to Gleason 9, this does not necessarily mean that recurrence will take place. Perhaps it is the new Gleason score that made your doctor recommend a radiation oncologist? If you see one, be sure that it is a very highly experienced person with your type of case. Could be that they may also say there is no need for any more treatment at this time -- and hopefully never.

My uneducated guess would suggest that you simply keep having regular PSA tests to keep on top of any changes. ONE NOTE: The first TRUE reading of your PSA will be about 3 months after surgery, but I would think your 0.02 2 months later is VERY good news! :)

Best of luck to you!
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.

Post Edited (HighlanderCFH) : 3/4/2013 6:16:06 PM (GMT-7)

distal urethra margin positive. focus left posteria margin pos .2cm left anterial positive .1cm

With Gleason 9 and positive margins I think radiation and HT are the next step. Of course the radiation won't start until you heal from the surgery. Good luck going forward.