Restage to pT3b after failed LRRP

I went to see urologist in April 2013 because my PSA was 9.9 and I had urinating and ejaculating problems. Biopsy performed with 12 samples taken. Four samples came positive: one 4+3 30% involvement, one 3+4 of 5% and two 3+3 of less than 5%.
I decided to undergo daVinci robotic surgery. My surgeon suggested hormonal downsizing of the prostate (130g) for four months prior to the surgery by taking Firmagon injections. Prostate after that was 67 g about half of original size.
On 9/3/2013 Surgery took 4.5 hours and pathology report came with pT2a with left seminal vesicle not present and right only focal with no invasion, Gleason score 3+4 with tertiary 5, 2% of tumor involvement, EPE negative, surgical margins negative, perineural invasion and multifocal PIN, lymph nodes not sampled.
PSA on 10/16/2013 0.01, 2/4/2014 0.05, 6/11/2014 0.16!
Because of fast rising PSA MRI of pelvis and abdomen was ordered and report show that seminal vesicles still present and left has a nodule about 7mm what is “suspicious for cancer recurrence”. My new stage is pT3b.
I was sent to radiation oncologist and we decided on hormonal therapy Lupron and casodex starting in June 2014 before 40 sessions of radiation between August and October 2014 (15 sessions of 3D conformal for pelvis and 25 sessions of IMRT targeted on particular areas)
Radiation total of 72 Gy and my onc wants me on 2 year of Lupron.?
First PSA after radiation on 12/3/2014 is 0.00!!!!!
Recently I obtain Operative Report of my prostate and find out that surgeon removed prostate in two pieces because median lobe was large and “obstructed vision during operation”.
Is prostate 130g too big for successful LARP?
Any input greatly appreciated.

I'm confused. Did you say that both seminal vesicles were not removed and now one is cancerous? That seems very unusual. I did not think that SVs were ever left behind.
Bob

I find it strange that he didn't remove both seminal vesicles as well, but at this point, what's there to be done about it? I'm glad the ADT is keeping your PSA undetectable.

- Allen

I’m glad ADT keeps PSA undetectable after 40 treatments and 72Gy of Salvage RT.
Now PSA reading is affected by ADT and after Lupron stop working we can tell exactly how successful is this treatment.
In my case a plan is for 24 months of ADT (Lupron injection) and it’s going to take probably one more year to clear Lupron from the body.
In May 2013 I had severe inflammation of the prostate. It was treated with antibiotics.
In that time PSA jump from 7 to ~10 ng/ml and at the same time my ejaculation was drastically changed from normal volume to almost nothing.
I think that was invasion of seminal vesicles it was later confirming by MRI.
What’s puzzle me is that cancer volume in prostate was about 2% and still cancer escaped prostate and invaded seminal vesicle.
Looking at your signature Bob I see that my treatment and stats are somewhat similar to yours.
The difference is ADT.
If I’m correct your ADT was six months and my might be 24 months.
Bob and Allen I thank you for your advice.

Mark said...
What’s puzzle me is that cancer volume in prostate was about 2% and still cancer escaped prostate and invaded seminal vesicle.

I suspect it was those nasty tertiary 5s that got loose.

- Allen

Billy, tertiary 5 would be the third grade of cell they found on the pathology.

Cheers, Doug

focal means a very small amount of cancer but dependent on gleason and where it is, can be prognostic. I had 2 "foci" {presumely foci are even smaller than a focus}gl grade 5. google foci and pca. I found an interesting article that said the "majority" of foci are grade 3; but the danger is if it is a 5 and they can be, it can be overlooked by pathologist. I have no idea how to create a link so did not. Pca is usually a multi focus disease. It can pop up here there and every where., seemingly independent of one to the other, hence the different grades.

Well hell, somehow I missed this tertiary 5 business. I'll have to go back and look at my path report. I suppose this is something you might see in both BX and post op path?

Allen said...
A tertiary 5 raises the risk level of what would ordinarily be intermediate risk to high risk.

Allen,

What is your take on this dilemma?
Before robotic prostatectomy I had hormonal therapy firmagon shots for four months (to shrink 130g prostate)
Pathology report after LARP assign Gleason score 3+4=7 with tertiary 5.
I sent a slides to University of Chicago for second opinion .They said “Gleason grading is not applicable because prior hormonal therapy”
My needle prostate biopsy before prostatectomy was 4+ of 12 samples: one 4+3 30%, two samples 3+3 less than 5% and one sample 3+4 less than 5%.
Now the question is: what is my Gleason score, and am I intermediate or very high risk?

Mark

Mark,
They are right that Gleason grading is considered inaccurate after hormone therapy, although a recent study from the Mayo Clinic calls that into question.(They looked at biopsy Gleason scores, rather than pathology Gleason scores.)

Gleason grading after neoadjuvant hormonal therapy retains prognostic value for systemic progression following radical prostatectomy.

More to the point of your question is that all of that is irrelevant now. Risk categories like "low", "intermediate", or "high" risk are only useful in guiding primary treatment decisions. Those risk groups are not used after a recurrence (which is designated R+), and they usually call what you had after prostatectomy as "recurrent" or "locally advanced." Now, after hopefully successful salvage RT, they would consider you to be "bNED" - biochemically no evidence of disease.