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G9/PSA27.16/ T3b N0M0 Possible. Surgery?

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Posted 1/13/2015 4:05 PM (GMT 0)
Easy guys its only our ego's and civility at stake here!
Posted 1/13/2015 4:49 PM (GMT 0)
Just a comment:

We are all imperfect humans.

I know that Tall can come down as a tad overbearing at times, but then again he does more research than anyone else here. I have appreciated his input and insight into my personal PC battle. But I still make my own decisions.

Hawaii: I guess I see absolutely nothing wrong in his query about your T-level. He is trying to be helpful. I didn't know he needed an invitation to ask about your T-level. It is an important bit of information. I guess I didn't see any hint of anything wrong in such an innocent question.

Anyway, I know the stress of this disease can make us all irritable!

I know that first-hand (thank you, f-HT)

Mel
Posted 1/13/2015 4:53 PM (GMT 0)
What is the difference between PT3A and PT3B?

Mel
Posted 1/13/2015 5:40 PM (GMT 0)
pT3a = extraprostatic extension found in post-op pathology
pT3b = seminal vesicle invasion found in post-op pathology

pT3b usually has a worse prognosis than pT3a.
Posted 1/14/2015 3:49 AM (GMT 0)
*NERD alert* - Read no farther if you aren't PDA or another nerd.

PDA said...
It's just when you start doing math with the relative risks of recurrence for radiation at four and five years vs surgery at ten and fifteen years that I point out the apples and oranges problem. I know that the data one would need for a real comparison are hard to find, and quite likely doesn't exist, but I do feel compelled to point out the difficulty you are facing in making the comparison.

I'd describe it more as apples vs older apples. The bigger difficulty is finding data based on clinical risk features, rather than pathological risk features. Clinical risks is all that we know before we make any decision to treat. A clinical stage T3 is riskier than a pathological stage T3. It also has to be based on results in the PSA-screening era. I think I found something that would suit you - the Stephenson nomogram.

Here it is:
Stephenson nomogram

Now forgive me if I'm off by a couple of points here and there because I'm trying to read it off my computer screen with a straight-edge. So for pzhope's father's stats, I come up with:

Pre-op PSA (27) - 85 pts
# positive cores (12) - 27 pts
# negative cores (0) - 60 pts
Clinical stage (T3) - 37 pts
Biopsy- 1° Gleason (4) - 60 pts
Biopsy - 2° Gleason (5) - 70 pts
TOTAL - 279 pts

Now, at 5 years (60 months) - this hits the 30% curve. So with his current stats, he only has only a 30% probability of being PSA progression-free at 5 years if he chooses surgery. I know we don't have a similar nomogram for HDR+IMRT, but starting with a progression-free probability of 90+% for a guy with average high risk stats, it's hard to see how he wouldn't be better off. At the very least, it merits a conversation with an HDR brachy specialist, don't you think?

I also see that with the very high risk stats, there's a strong possibility it has already micro-metastasized, in which case there's a probability that no treatment would be curative. There may be a benefit, however, in de-bulking the primary source - either with radiation or surgery - and it would seem that HDR+IMRT has the better side effect profile.

- Allen
Posted 1/14/2015 5:21 AM (GMT 0)
Tall,

I quite agree that surgery as a mono-therapy is unlikely to be sufficient for pzhope's father. His surgeon told him as much

His surgeon said...
The surgeon never gave us a firm recommendation. He just said surgery is possible or radio therapy. Either way my dad needs to have multimodal therapy.

I tend to think of HDR brachy and surgery as occupying more or less the same place in building a multi-modal treatment plan. Both thoroughly deal with the prostate and both need a bit of radiation for the surrounding tissues when it is likely that the disease has escaped from the prostate. HDR does have a better side-effect story but surgery provides a post-op pathology report which allows part of the treatment to be tweaked using pathological (as opposed to clinical) risk features.

And, yes, of course he should talk to a brachy specialist.
Posted 1/14/2015 5:46 AM (GMT 0)
PDA,

PDA said...
...but surgery provides a post-op pathology report which allows part of the treatment to be tweaked using pathological (as opposed to clinical) risk features.

How does a path report help if one already knows the seminal vesicles are cancerous? What kind of "tweaking" do you imagine? It's a choice of IMRT to the local area on top of cut and handled tissue, or IMRT to the local area on uncut, unhandled tissue.

- Allen, Tall
Posted 1/14/2015 6:36 AM (GMT 0)
Hi pzhope,
Welcome to HW! I have found this site to be so informative and the guys have a lot of knowledge and experience to help you make informed decisions in conjunction with your medical team. You need to forgive their occasional jabs at one another. They're human and can get a little testy (the HT causes that too, little testies) Sorry for the bad humor guys! There is a thread called caregivers corner you want to check out too. Best wishes to you and your dad, whatever treatment path you choose.
Beth n Gary
Posted 1/14/2015 9:38 PM (GMT 0)
Celebrate,

"little testy" / "little testes"? ... Haw! I get it... [collapses sobbing]...

Ok, I'm better now. I blame the Lupron.

---

Pzhope,

I have an ongoing debate with Tall Allen about the relative merits of surgery and radiation for higher risk disease. Without conceding the debate I must admit that this thread represents a poor choice of venue on my part for continuing the debate since your dad's case better fits Tall's argument than mine.

Tall Allen's suggestion that your dad talk to an RO who does HDR brachytherapy is really good advice.
Posted 1/15/2015 9:10 PM (GMT 0)
PZHOPE,
I had 6 specimuns on one side with 80-90% tissue involved at Gleason 8. Another hospital rated them G8-9. I got a list of the best surgeons in my area and met with them all. The all said that the current thinking is to get the prostate out. The other major conclusion that I came to was that with G9/8 and 80% plus involvement, that my best chance for negative margins was with full radical prostatectomy surgery. Two surgeons who each had done more than 4000 convinced me in great detail how they can feel with their fingers where the cancer ends and achieve the best margins possible. I did not get this sense of confidence when I peppered three accomplished robotic surgeons with the same questions on margins for my case.
Posted 1/16/2015 5:55 AM (GMT 0)

PeterDisAbelard. said...
................................................
All that said, I remain something of a supporter of surgery, even if I am not the sort of poster-child that the makers of the DaVinci robot might have in mind. I often think the Tall one adds just a hint of torque to spin the excellent information he give us. Instead of saying "The published outcomes for multi-modal radiation treatment for high-risk patients is actually far better than for surgery" I might have said "The published outcomes for multi-modal radiation treatment for high-risk patients is actually even better than for surgery."

I was about to start a new thread on this subject and maybe I still will, but for now I will just throw some of that discussion in here.

Soon after my surgery, I became fairly convinced I had made the wrong choice. Not just because of the SEs, but because I was not contained as my surgeon felt I might well be(only way to know that was by surgery). So, I was thinking: if I am probably going to need RT or HT someday anyway, why didn't I just get it to start with and maybe have avoided some of the severity of SEs? But, a few things have clouded the picture for me.

First, we have had a few studies posted here where long term follow up(10-20 yrs) for surgery on G8-10s had results that were fairly encouraging it seemed to me, like this one:
www.renalandurologynews.com/study-supports-surgery-for-high-risk-prostate-cancer/article/338483/
Of course, that is just one study and it may be contradicted by others. Still, hopeful.

But even more confusing was a study we discussed briefly here recently. It compared the outcomes of patients whose RP was cancelled(RP-) - then placed on HT only I believe- when it was discovered it had already spread to their lymph nodes, vs those with positive LNs who had the RP anyway(RP+ and HT therapy). To my surprise, the patients who had RP did quite a bit better as far as lack of recurrence and/or survival.
www.pubfacts.com/detail/20942833/Radical-prostatectomy-improves-progression-free-and-cancer-specific-survival-in-men-with-lymph-node-

So I keep thinking about that. If it is already out in the LNs, how can surgery help prevent further spread and help survival? Regardless of why, out in the LNs is- I think- a good bit worse than the positive(foci) margin and +SVs I had, the reasons I was wishing I had had RT instead. But, if surgery can improve matters at 10 yrs quite a bit for LN+ folks(almost double the Clinical progression free survival(61% vs 31%)- who they used to cancel RP for- then who would not have a better survival rate with surgery? Cancer specific survival at 10 yrs was 76% for surgery vs 46% for HT only. Those are some pretty stout differences, for whatever reason. I guess this is why when I asked my surgeon if they would check LNs 1st and cancel RP if it was already spread there, he told me that was kind of old fashioned thinking.

So I suppose with bone mets surgery might not help? Then again, I don't know why it helps when LNs are positive. So it seems possible it might even be helpful with bone mets?

Anyway, even though I did not have LN+, though I did have SV+, G9 and positive margin foci, the above has made me reconsider whether having chosen surgery- in hindsite based on path report- was a mistake. Again, I am trying to figure out: if surgery helps(a good bit) even those with positive LNs, who will it not help, other than maybe + mets? I may not care for the SEs of the surgery, but MAYBE it actually improves my survival chances?

Of course, the trouble always is, there are probably other studies completely contradicting all of the above. For that matter, I found some studies at the DaVinci site that showed much better results with surgery compared to HT or RT or both, go figure!(can't seem to find that now)
Posted 1/16/2015 6:06 AM (GMT 0)

Tall Allen said...
pT3a = extraprostatic extension found in post-op pathology
pT3b = seminal vesicle invasion found in post-op pathology

pT3b usually has a worse prognosis than pT3a.

Is the prognosis for positive lymph nodes any different than for positive SV?
Posted 1/16/2015 6:55 AM (GMT 0)
Billybob,
According to AJCC Staging guidelines, N1 is Stage IV no matter what, while pT3 with N0 is Stage III, so positive lymph nodes (N1) has a worse survival prognosis, but survival may be 20 years or more. Because we can't wait 20 years to prove a new therapy on the basis of PC survival, we have to look at surrogate endpoints, like biochemical recurrence-free survival (bRFS). I can't guarantee that better bRFS will result in better survival rates 20 years down the road, but odds are that it will.

Neither of the studies you linked to apply to this case. The research on surgical outcomes I quoted were not dealing with GS 8-10, they were dealing with clinically diagnosed Stage T3 - a very different matter, and one which doesn't apply to your case. So there is nothing I described here that would lead you to second guess yourself -- a fruitless enterprise at any rate. It's all about what we do from this point forward. We have no control over the past, and we can only make guesses with probabilities about future outcomes sometimes. Only the present is in our hands.

I don't think there's any question that RP with extended lymph node dissection (ePLND) holds better odds compared to a strategy of aborting the RP and just giving palliative hormone therapy when positive LNs are detected. But I don't see how that helps in choosing RP over RT as primary treatment.

- Allen
Posted 1/17/2015 5:43 PM (GMT 0)

Tall Allen said...
Billybob,
According to AJCC Staging guidelines, N1 is Stage IV no matter what, while pT3 with N0 is Stage III, so positive lymph nodes (N1) has a worse survival prognosis, but survival may be 20 years or more. Because we can't wait 20 years to prove a new therapy on the basis of PC survival, we have to look at surrogate endpoints, like biochemical recurrence-free survival (bRFS). I can't guarantee that better bRFS will result in better survival rates 20 years down the road, but odds are that it will.

Neither of the studies you linked to apply to this case. The research on surgical outcomes I quoted were not dealing with GS 8-10, they were dealing with clinically diagnosed Stage T3 - a very different matter, and one which doesn't apply to your case. So there is nothing I described here that would lead you to second guess yourself -- a fruitless enterprise at any rate. It's all about what we do from this point forward. We have no control over the past, and we can only make guesses with probabilities about future outcomes sometimes. Only the present is in our hands.

I don't think there's any question that RP with extended lymph node dissection (ePLND) holds better odds compared to a strategy of aborting the RP and just giving palliative hormone therapy when positive LNs are detected. But I don't see how that helps in choosing RP over RT as primary treatment.

- Allen

OK, thank you for that further explanation Allen. If I am understanding you correctly, if I had N1 my prognosis would be worse that with just the T3B(?) SV invasion that I actually had? If so, that is some good news that I may not have been quite clear on earlier. While I knew the LN- or N0 was good news, I guess I was not certain if it was more or less negated by the SV invasion plus a positive margin foci. Sounds like it was not negated.

I probably did not get my point across with my rambling, and still may not be able to now with further rambling.

I was 2nd guessing myself(fruitless true, but there it is) not from anything you had posted, but simply based on the idea that was causing me trouble even before I finally submitted to surgery. Despite my surgeon's feelings that I was likely contained, and that if I was contained he could offer me a cure, but that with radiation we would not know until months or years later if it was out of the capsule and indeed out into the lymph nodes, despite all that I was not sure that was the best argument.

Because I kept thinking: if it is out of the capsule and/or into the SV ( leaving LN out for the moment) and if (because it was outside the capsule)I was going to have to come back later for RT anyway, wouldn't it be better to just start with the RT, and zap outside the capsule from the get go? OTOH, only the surgery would leave me knowing about how much it might be out(if any) and certainly about the LNs. This was a nearly impossible decision for me. I guess in the end I decided, by a very small margin, that it would be better to know.

So now I know. And once I knew that even though I was N0 yet I still had a positive margin and SV+, I couldn't help but wonder if RT primary would not have been the better decision, plus likely fewer permanent SEs. That has weighed on my mind since then.

However, the point I may have failed to make about the study re: LN and discontinued vs continued RP: My previous impression or at least feeling- as stated above- if the cancer is out of the capsule, then starting with surgery may not be the best idea, better to start with RT if you could know that before hand. IOW, how much good is surgery going to do if it is already out of the capsule? It just seems like RT- if maybe not HT only- would be the better option.

BUT, according to this study(FWIW), even when the cancer was way out of the capsule, in the LN or stage 4 as you clarified for me- doing the surgery was a great help, at least compared to HT alone. Can we also also make the leap that it is a big help even compared to doing nothing? Seems like it but we need the study. Now, I agree with "I don't see how that helps in choosing RP over RT as primary treatment.". RT may still be the better option, maybe. However, my thinking was that if it was out, surgery was not really going to be of any help. But if in fact, even if it is not only slightly out of the capsule and even SV but even stage 4 and out in the LNs, and surgery doubles the survival compared to HT alone( and maybe also compared to doing nothing? but compared to RT alone?), then it seems to me that surgery is indeed very helpful even if the PC is out of the capsule.

So though I am surprised at those results, surprised that surgery helped that much if the PC was already in the LNs, if their conclusion is true, then I may very well have helped myself by having the surgery. Because if it can help even if in the LNs, then it seems logical that it can help as much or more if it is only in the margins or SVs.

Now, when it is out, even out in the LNs, how much does surgery help compared to starting with RT as primary? Different question, even though it appears it is definitely helpful. But if only in the SV and just outside the capsule/surgical margins, maybe RT primary will be more helpful and even with less SV. Seems lkely.

But what about RT primary if it is pN1? How does that work? I guess you could do the LN BXs first, cancel the RP if pN0 and go to RT? But if pN1, what would be the the RT approach then? I understand that RT gets more of the prostate bed/margins/SV than does surgery, but what about the LNs? And must you do a surgical LN dissection to even know?

And the final question grand finale(maybe LOL!): what about RT primary vs surgery + RT/HT when/if needed? Or should I add when looking at G8+? Comparative long term survival rates?

Sorry Y'all for all the rambling and questions, my head is spinning. But the one thing I do take from that study: Even though my cancer was outside the capsule, it seems quite likely that my surgery will have helped my long term survival, even though I don't know if it will help as much or more than primary RT. So I do feel better in regards to that. And apologies to the OP(PZ) if my posts simply do not apply to their questions. Like I said, I was going to start a new thread and I see I probably should have. Mods, please move my posts and Allen's or others responses to them to a new thread if I have messed up placing this here.
Thx Bros,
Bill

Post Edited (BillyBob@388) : 1/17/2015 9:25:51 PM (GMT-7)

Posted 1/19/2015 5:01 AM (GMT 0)
Hi Everyone,

Sorry for the late reply and information here. I have been really busy helping my dad meet with different oncologists and surgeons in the valley. Did not get time to post anything here. Sorry for the delay. Really appreciate every post here, thank you all!

My dad has decided that he will have the surgery to remove the entire prostate and surrounding lymph nodes through robotic surgery. The surgeon at Mayo Clinic AZ suggested us to do so as he said the best treatment from their knowledge for g9 cancer is surgery + HT. He said something about the G9 cancer cells proliferate so fast, radiation sometimes cannot catch the speed. My dad will get radiation if the margin is positive. The surgeon also said only when you see what's going on at prostate can give you some idea of what you are dealing with (i know, this is such a cliche.). I told my dad about all side effects and it seems he really wants to get the stuff out of his body to ease his mind a little bit. The doctor also mentioned multimodel therapy, and he said the findings during the surgery would give an indication of the treatments afterwards.

I will update once my dad is done for the surgery (he's scheduled tomorrow, finger crossed!!! Hope he's ok... I mainly concern about lymph nodes involvements even though his CT and bone scans are all negative.) I will update again after the surgery. Thank you, everyone! Best wishes to you all!
Posted 1/19/2015 5:04 AM (GMT 0)
Hi Bilybob,

YOur information is very helpful. Please include me in your new thread. I would like to get all your discussions along with all replies.

Thank you.




BillyBob@388 said...

Tall Allen said...
Billybob,
According to AJCC Staging guidelines, N1 is Stage IV no matter what, while pT3 with N0 is Stage III, so positive lymph nodes (N1) has a worse survival prognosis, but survival may be 20 years or more. Because we can't wait 20 years to prove a new therapy on the basis of PC survival, we have to look at surrogate endpoints, like biochemical recurrence-free survival (bRFS). I can't guarantee that better bRFS will result in better survival rates 20 years down the road, but odds are that it will.

Neither of the studies you linked to apply to this case. The research on surgical outcomes I quoted were not dealing with GS 8-10, they were dealing with clinically diagnosed Stage T3 - a very different matter, and one which doesn't apply to your case. So there is nothing I described here that would lead you to second guess yourself -- a fruitless enterprise at any rate. It's all about what we do from this point forward. We have no control over the past, and we can only make guesses with probabilities about future outcomes sometimes. Only the present is in our hands.

I don't think there's any question that RP with extended lymph node dissection (ePLND) holds better odds compared to a strategy of aborting the RP and just giving palliative hormone therapy when positive LNs are detected. But I don't see how that helps in choosing RP over RT as primary treatment.

- Allen

OK, thank you for that further explanation Allen. If I am understanding you correctly, if I had N1 my prognosis would be worse that with just the T3B(?) SV invasion that I actually had? If so, that is some good news that I may not have been quite clear on earlier. While I knew the LN- or N0 was good news, I guess I was not certain if it was more or less negated by the SV invasion plus a positive margin foci. Sounds like it was not negated.

I probably did not get my point across with my rambling, and still may not be able to now with further rambling.

I was 2nd guessing myself(fruitless true, but there it is) not from anything you had posted, but simply based on the idea that was causing me trouble even before I finally submitted to surgery. Despite my surgeon's feelings that I was likely contained, and that if I was contained he could offer me a cure, but that with radiation we would not know until months or years later if it was out of the capsule and indeed out into the lymph nodes, despite all that I was not sure that was the best argument.

Because I kept thinking: if it is out of the capsule and/or into the SV ( leaving LN out for the moment) and if (because it was outside the capsule)I was going to have to come back later for RT anyway, wouldn't it be better to just start with the RT, and zap outside the capsule from the get go? OTOH, only the surgery would leave me knowing about how much it might be out(if any) and certainly about the LNs. This was a nearly impossible decision for me. I guess in the end I decided, by a very small margin, that it would be better to know.

So now I know. And once I knew that even though I was N0 yet I still had a positive margin and SV+, I couldn't help but wonder if RT primary would not have been the better decision, plus likely fewer permanent SEs. That has weighed on my mind since then.

However, the point I may have failed to make about the study re: LN and discontinued vs continued RP: My previous impression or at least feeling- as stated above- if the cancer is out of the capsule, then starting with surgery may not be the best idea, better to start with RT if you could know that before hand. IOW, how much good is surgery going to do if it is already out of the capsule? It just seems like RT- if maybe not HT only- would be the better option.

BUT, according to this study(FWIW), even when the cancer was way out of the capsule, in the LN or stage 4 as you clarified for me- doing the surgery was a great help, at least compared to HT alone. Can we also also make the leap that it is a big help even compared to doing nothing? Seems like it but we need the study. Now, I agree with "I don't see how that helps in choosing RP over RT as primary treatment.". RT may still be the better option, maybe. However, my thinking was that if it was out, surgery was not really going to be of any help. But if in fact, even if it is not only slightly out of the capsule and even SV but even stage 4 and out in the LNs, and surgery doubles the survival compared to HT alone( and maybe also compared to doing nothing? but compared to RT alone?), then it seems to me that surgery is indeed very helpful even if the PC is out of the capsule.

So though I am surprised at those results, surprised that surgery helped that much if the PC was already in the LNs, if their conclusion is true, then I may very well have helped myself by having the surgery. Because if it can help even if in the LNs, then it seems logical that it can help as much or more if it is only in the margins or SVs.

Now, when it is out, even out in the LNs, how much does surgery help compared to starting with RT as primary? Different question, even though it appears it is definitely helpful. But if only in the SV and just outside the capsule/surgical margins, maybe RT primary will be more helpful and even with less SV. Seems lkely.

But what about RT primary if it is pN1? How does that work? I guess you could do the LN BXs first, cancel the RP if pN0 and go to RT? But if pN1, what would be the the RT approach then? I understand that RT gets more of the prostate bed/margins/SV than does surgery, but what about the LNs? And must you do a surgical LN dissection to even know?

And the final question grand finale(maybe LOL!): what about RT primary vs surgery + RT/HT when/if needed? Or should I add when looking at G8+? Comparative long term survival rates?

Sorry Y'all for all the rambling and questions, my head is spinning. But the one thing I do take from that study: Even though my cancer was outside the capsule, it seems quite likely that my surgery will have helped my long term survival, even though I don't know if it will help as much or more than primary RT. So I do feel better in regards to that. And apologies to the OP(PZ) if my posts simply do not apply to their questions. Like I said, I was going to start a new thread and I see I probably should have. Mods, please move my posts and Allen's or others responses to them to a new thread if I have messed up placing this here.
Thx Bros,
Bill

Posted 1/19/2015 5:50 AM (GMT 0)
Billybob,

I'm afraid I got lost in your ramblings.

If you're asking if there is value in de-bulking the primary tumor source even when it is diagnosed as metastatic (M1), the answer is there are no definitive answers yet, but it may be true based on some retrospective studies. Retrospective studies, especially such as the ones on de-bulking/cytoreduction, are notoriously prone to an error called "selection bias." But there is some science behind it from our experience with other cancers, and from lab studies. However, the survival benefit, to the extent that there is one, is equally true whether you surgically cut out the prostate and pelvic LNs, or whether you deliver pelvic radiation with a brachy boost to the prostate. The side effect profiles of those choices are very different.

I hope that answered your question, if there was a question.

- Allen
Posted 1/19/2015 12:18 PM (GMT 0)
My treatment plan is at least tangentially related to this discussion.

We opted for primary RT, and added all the pelvic lymph nodes to the radiation volume. They all got 50.4 Gy, while the prostate was further treated to 79.2 Gy.

We went after the lymph nodes due to my G9 cT3a diagnosis. All factors considered, there was something like a 40% chance of the lymph nodes already being involved even though they didn't show such on the 3T-MRI. So we decided to bake them too.

My uro onc was careful not to make recommendations for treatment, but he was not very encouraging about surgery for me. He said it would have to be a "very wide excision", without ability to do "luxury things" like nerve sparing and so on. The clear impression was surgery was not likely to be curative and we would have serious incontinence risk and of course total ED. The main reason I'd have gone for surgery was to avoid the whole spectrum of radiation and HT side effects, but failed surgery would put me right there anyway.

The RO was much more positive about catching it with the planned treatment volume while minimizing nasty side effects. They made a 10mm margin around the lymph nodes, 7mm around the prostate except at the rectal wall where they did a 4mm margin. With IGRT they can be that precise. Interestingly, all through my RT they asked me regularly and directly about side effects, and seemed rather surprised and relieved that I was not having any of the unpleasant ones ("leakage", loose bowels, rectal bleeding, fun stuff like that). Never have, so I'm very happy with RT side effects so far.

By the way, the comment about G9 cells proliferating too fast for radiation to catch them is a new one to me. Never heard that angle before. It did take two months of HT and then over two more months to complete the radiation series. Surgery would have yanked the thing as soon as it's done. Interesting thought, but not sure about that one. All the studies with RT+ neoadjuvant HT would have the same timing issue vs. surgery, but I've never seen that discussed.

HT side effects I'm much less happy about, but perhaps I'll recover when we stop that.

Jerry
Posted 1/19/2015 1:02 PM (GMT 0)
PZhope,

Good luck to your dad. Let us know how the surgery goes. We'll be here.
Posted 1/20/2015 5:08 PM (GMT 0)
Thank you, PZ. I'm glad you found my ramblings helpful. good luck on your Dad's surgery! I have not yet started a new thread on the subject of "is surgery helpful even if it has escaped the capsule". I have for the moment gotten lost and started rambling over in TA's thread about SALVAGE RT.

Tall Allen said...
Billybob,

I'm afraid I got lost in your ramblings.

If you're asking if there is value in de-bulking the primary tumor source even when it is diagnosed as metastatic (M1), the answer is there are no definitive answers yet, but it may be true based on some retrospective studies. Retrospective studies, especially such as the ones on de-bulking/cytoreduction, are notoriously prone to an error called "selection bias." But there is some science behind it from our experience with other cancers, and from lab studies. However, the survival benefit, to the extent that there is one, is equally true whether you surgically cut out the prostate and pelvic LNs, or whether you deliver pelvic radiation with a brachy boost to the prostate. The side effect profiles of those choices are very different.

I hope that answered your question, if there was a question.

- Allen

My apologies for my ramblings, TA, I know I am prone to do that. And yes there were some questions in there and I think you have answered at least some of them. Also, I think the final question, which was "And the final question grand finale(maybe LOL!): what about RT primary vs surgery + RT/HT when/if needed? Or should I add when looking at G8+? Comparative long term survival rates?" might have been one factor leading to your current very busy thread on SRT. Thanks for trying to clear things up for me.
Posted 1/22/2015 1:56 AM (GMT 0)
Hi Everyone,

I have some updates. My dad has already been discharged from Mayo AZ. I just got off the phone with the surgeon regarding his path report. Good news is his lymph nodes are all clean but bad news is that post-op revealed his G9 nature and both of his seminal vesicles are involved. There are positive margin as well. In general his at T3bN0M0. Based on Dr's words, my dad will get multi-model therapy with HT first as soon as he gets his catheter out. We will meet with Radiation Oncologist on Monday to hear the following treatment plans. The surgeon told me the prognosis of my dad's case depends on whether his cancer cells respond to the radiation. Also if the first PSA after 3 months comes undetective (finger crossed..), he will have a long life expectancy. But if he does not have a good radiation response, then his prognosis is not going to look good.

Thank you all for all the support and suggestions. I will update frequently once he receives the RT and HT.

P.S. if lymph nodes are clean, what are the chances?
Posted 1/22/2015 3:43 AM (GMT 0)
Hi pzhope, thanks for the update. Most important, I'm glad that your dad is home and I wish him all the best for a rapid recovery. Unfortunately, his pathology isn't great in terms of the positive margins. But there are guys here (wish I could recall who off the top of my head) that were G9 with positive margins are doing well. You may want to post a new thread specifically about that as it will probably get some more specific replies.

In terms of radiation I think the question is whether the cells are still in the prostate bed, which is what the radiation targets. I would ask about the RO about the plan and what the target is for the radiation. Even though the lymph nodes are clean, I would assume they might be targeted as well.

I think your dad can still can do well. Wishing him a quick recovery from surgery. Keep us posted.
Posted 1/22/2015 5:24 AM (GMT 0)
I am a Gleason 9 who had positive margins. I'm a bit lower risk than your dad since my cancer had not reached the seminal vesicles, but I had pretty much the same multi-modal treatment your dad is looking at -- surgery followed by radiation and hormone therapy. The radiation wasn't difficult for me, and while the hormone therapy was my least favorite part, I got through it, eventually. Your dad should get through the treatments OK.

As for his chances, there are other guys who can quote this or that study and give you the odds to two decimal places but I can only say that his chances of a durable remission are a bit better than 50/50 with the radiation and the hormones. But if the radiation doesn't do it for him there are lots and lots of other treatments, and more coming in the pipeline every day. Either way he'll be with you for a long time to come -- the main difference will be how much of his time will be tied up in cancer treatments.
Posted 1/22/2015 5:27 AM (GMT 0)

pzhope said...
Hi Everyone,

I have some updates. My dad has already been discharged from Mayo AZ. I just got off the phone with the surgeon regarding his path report. Good news is his lymph nodes are all clean but bad news is that post-op revealed his G9 nature and both of his seminal vesicles are involved. There are positive margin as well. In general his at T3bN0M0. Based on Dr's words, my dad will get multi-model therapy with HT first as soon as he gets his catheter out. We will meet with Radiation Oncologist on Monday to hear the following treatment plans. The surgeon told me the prognosis of my dad's case depends on whether his cancer cells respond to the radiation. Also if the first PSA after 3 months comes undetective (finger crossed..), he will have a long life expectancy. But if he does not have a good radiation response, then his prognosis is not going to look good.

Thank you all for all the support and suggestions. I will update frequently once he receives the RT and HT.

P.S. if lymph nodes are clean, what are the chances?

PZ, good to hear your Dad is out of his surgery. Like Michael_T just said, that path report(as expected) is not the greatest, but it is still possible for him to do well over the years: you just never know! If you have not already, go read the current thread by Gunner34. Can't remember: did you dad have any mets?

Actually, your Dad's post op path report reads almost identical to mine, though my one positive margin had the term foci with it, which I think meant very small. But, a positive margin it is. Unfortunately, I am only in my 11th month post(just started my 12th) so no long term report for me yet. But, so far, so good. I actually had another bone scan and PSA in August here with my local UROs because I was having worsening hip pain, but the 2nd scan was clear and PSA was still < 0.01. I had another PSA in October, up in Nashville(Vanderbilt) where they did my surgery. They don't use the ultra-sensitive for what ever reason up there, but I was still showing undetectable by their standards: <.1. I missed an appointment so won't have another until March.

Here is the odd thing. Although your Dad's pre-op PSA was a lot more than mine, and his Bx had a higher % of positive cores and G9s than me, still the post op path seems about the same, maybe identical. But my doc up at Vanderbilt( J.A. Smith) has not recommended any ART or HT for me, and will not until my PSA rises above .2, I think he said, at which time we will discuss the pros and cons of other treatment. Now before any one calls him behind the times or a nut, consider that he has authored or Edited 8 books related to PC or chapters in them, including(with Tewari) Robotic Urological Surgery in 07 and Hinman's Atlas of Urologic Surgery in 08 and all the way back to 87 Clinical Management of Prostatic Cancer. And among many, many other things he is a current Associate Editor of Journal of Robotic Surgery as well as on the Editorial board of Prostate Cancer and Prostatic Diseases. And on and on ad infinitum.

Why am I pointing all of that out? Though I'm sure there are studies out there indicating I should be on more aggressive therapy now, I'm pretty sure he is well aware of all the different studies as he has authored quite a few of them himself. I count at least 122 at Pub Med(maybe 200+ if the J.Smith writing about prostates is the same as JA Smith) including www.ncbi.nlm.nih.gov/pubmed/25378826 and www.ncbi.nlm.nih.gov/pubmed/24746665 . So he may be at least as capable as I am on judging if I would benefit from early RT or HT. And he seems to think I have about a 50% chance of not needing further treatment, and if I do need it I will do as well by waiting as long as a PSA .2 will allow me to delay.

Therefore, if he thinks that I, with a path report similar to your Dad's, can do OK(may he be right! LOL! ) by waiting for SRT until clearly needed, then your Dad may well have just as good(or many would argue much better) odds as me with all of the treatment he is hitting this with. He has a fair chance of doing very well, I would think! And may he indeed do great!
Bill
Posted 1/29/2015 10:03 PM (GMT 0)
Hi BillyBob,

Really appreciate your input here and the share of your story. Sorry I havn't been active on this forum lately. It's been crazy busy for me these two weeks, both family and from work.

The final path report came out and here is the notes:

A. Perirectal tissue, right, biopsy: benign fibromuscular tissue and fat without prostatic glands or tumor.
B. Prostatic urethra, biopsy: Prostatic urethral tissue involved by poorly differentiated prostatic adenocarcinoma.
C. Prostatic urethra at 6 o'clock, biopsy: Fragment of fibromuscular prostatic urothelial tissue with focal crushed atypical cellularity of uncertain significance.
D. Rectourethralis tissue, biopsy: Benign fibroadipose tissue without evident tumor.
E. Prostate, radical prostatectomy with lymphadenectomy: prostatic adenocarcinoma.

Post-surgical Gleason score: 9 (4+5)

Tumor quantitation and location: tumor involves th egland bilaterally from apex to base in both peripheral zone and anteriorly, mainly in the lower portion of the gland.

Extraprostatic extension: present, in small foci bilaterally from apex to base anteriorly and posteriorly.

Margin: positive in multiple foci (anterior apex-approximately 6-mm contiguous length, left base - approximately 1 cm contiguous length). ---- is this very bad?????

Lymph-vascular invasion: Not identified.
Perineural invasion: present and extensive.
Seminal vesicle invasion: present bilaterally.
Lymph nodes: four lymph nodes negative for metastatic carcinoma.

Pathlogic staging (AJCC 2010): pT3b; pN0.

Ok, from here, you can see my dad has his prostate out and all involved with cancer cells with G9. The problem I have is that the report shows multi-foci positive margin but the surgeon said he took extra frozen region which closes to urethral neck that turned back to be negative. In another word, he took extra margin to see if he could get everything out and he did. Based on his description, everything's out from my dad and should be no positive margin. Is this right? He gave my dad a 4-month dose of lupron and asked him to check back by then.

Here comes another issue, we went to see the radiation oncologist the same day we met with the surgeon. I felt the surgeon was pretty confident about the surgery and did not recommend radiation right away (he said wait for 3-4 months to see if we should get the radiation dr. involved). However, the radiation oncologist seemed think otherwise. He said if it were himself, he would do the radiation after 3 months. He also gave us a paper study showing the survival rate with radiation after surgery is 10-15% higher than no radiation after surgery. He indicated that the hormone shot my dad was given would mean nothing regarding the cancer elimination since the hormone shot would press the testosterone and PSA should be very low (close to 0, if not, it's hopeless). The surgeon did not give my dad Casodex though so technically he still could produce the hormone from adrenal gland. Is this something we should be aware of? We don't know if he should follow up with radiation or not, seems a lot of ppl here went with radiation after surgery. Since he's given hormone shot, isn't it the way supposed to be? It seems your doctor did not recommend both of the treatment after surgery. Do you mind if you could share with us the reason?

I'm really confused with the report from pathology and the surgeon. maybe i did not understand quite clear from the surgeon but based on what he's been telling us, it seems the surgery went without any positive margin? According to the radiation oncologist, no surgery would leave with negative margin because when you cut the tissue, you would very possibly cut through the cancer cell and leave with fallen cells to prostate bed and that would be positive. Really confusing here...

Anyway, my dad does not know if he wants to do the radiation after all the hassle he's been through.. (he had his catheter put back on due to retention and should get it removed this friday.. but you know, he's frustrated and drives my mom crazy.. lol, he is also afraid of all the side effects that would occur after radiation). My thoughts on radiation is that it only radiates locally but if seminal vesicles are involved (only the tip of the base), very likely there's micro-mets that we don't know of. And locally radiation would not do any good? Just my thoughts... I could be very wrong about it...

Sorry for the lengthy post here... hopefully you will have the patient to read through and let us know your thoughts. Thanks...




BillyBob@388 said...

pzhope said...
Hi Everyone,

I have some updates. My dad has already been discharged from Mayo AZ. I just got off the phone with the surgeon regarding his path report. Good news is his lymph nodes are all clean but bad news is that post-op revealed his G9 nature and both of his seminal vesicles are involved. There are positive margin as well. In general his at T3bN0M0. Based on Dr's words, my dad will get multi-model therapy with HT first as soon as he gets his catheter out. We will meet with Radiation Oncologist on Monday to hear the following treatment plans. The surgeon told me the prognosis of my dad's case depends on whether his cancer cells respond to the radiation. Also if the first PSA after 3 months comes undetective (finger crossed..), he will have a long life expectancy. But if he does not have a good radiation response, then his prognosis is not going to look good.

Thank you all for all the support and suggestions. I will update frequently once he receives the RT and HT.

P.S. if lymph nodes are clean, what are the chances?

PZ, good to hear your Dad is out of his surgery. Like Michael_T just said, that path report(as expected) is not the greatest, but it is still possible for him to do well over the years: you just never know! If you have not already, go read the current thread by Gunner34. Can't remember: did you dad have any mets?

Actually, your Dad's post op path report reads almost identical to mine, though my one positive margin had the term foci with it, which I think meant very small. But, a positive margin it is. Unfortunately, I am only in my 11th month post(just started my 12th) so no long term report for me yet. But, so far, so good. I actually had another bone scan and PSA in August here with my local UROs because I was having worsening hip pain, but the 2nd scan was clear and PSA was still < 0.01. I had another PSA in October, up in Nashville(Vanderbilt) where they did my surgery. They don't use the ultra-sensitive for what ever reason up there, but I was still showing undetectable by their standards: <.1. I missed an appointment so won't have another until March.

Here is the odd thing. Although your Dad's pre-op PSA was a lot more than mine, and his Bx had a higher % of positive cores and G9s than me, still the post op path seems about the same, maybe identical. But my doc up at Vanderbilt( J.A. Smith) has not recommended any ART or HT for me, and will not until my PSA rises above .2, I think he said, at which time we will discuss the pros and cons of other treatment. Now before any one calls him behind the times or a nut, consider that he has authored or Edited 8 books related to PC or chapters in them, including(with Tewari) Robotic Urological Surgery in 07 and Hinman's Atlas of Urologic Surgery in 08 and all the way back to 87 Clinical Management of Prostatic Cancer. And among many, many other things he is a current Associate Editor of Journal of Robotic Surgery as well as on the Editorial board of Prostate Cancer and Prostatic Diseases. And on and on ad infinitum.

Why am I pointing all of that out? Though I'm sure there are studies out there indicating I should be on more aggressive therapy now, I'm pretty sure he is well aware of all the different studies as he has authored quite a few of them himself. I count at least 122 at Pub Med(maybe 200+ if the J.Smith writing about prostates is the same as JA Smith) including www.ncbi.nlm.nih.gov/pubmed/25378826 and www.ncbi.nlm.nih.gov/pubmed/24746665 . So he may be at least as capable as I am on judging if I would benefit from early RT or HT. And he seems to think I have about a 50% chance of not needing further treatment, and if I do need it I will do as well by waiting as long as a PSA .2 will allow me to delay.

Therefore, if he thinks that I, with a path report similar to your Dad's, can do OK(may he be right! LOL! ) by waiting for SRT until clearly needed, then your Dad may well have just as good(or many would argue much better) odds as me with all of the treatment he is hitting this with. He has a fair chance of doing very well, I would think! And may he indeed do great!
Bill

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