Recent prostatectomy, now T3b and concerned. Advice please!

Two week follow up since prostatectomy. Pre-op Gleaseon 3+4, PSA 4.6 originally diagnosed as T1c. Post-op pathology bumped me to T3b with seminal vesicle invasion and bladder neck invasion, PSA unchanged. Dr. Wants to wait three months for PSA retest and make a determination for radiation from there. Anyone with similar experience? Does three months seem like appropriate waiting for this scenario?

I didn't phrase my post very well. I haven't had a PSA done since surgery. The PSA that initiated diagnosis was 4.6 in April, 2015, up from 2.5 in April, 2014.
DaVinci 7/2/2014
Very light leakage< one pad
Impotence is improving much better than expected.

Your surgery was only two weeks ago and using one pad? That's good news! And if you are not having ED issues...that's great news!

Dugalf, welcome. My surgeon did a PSA at 6 weeks, and I was still above zero. The short answer to your question is yes, 3 months is standard protocol for PSA after surgery. Even if further treatment was indicated, waiting 3 months is post surgery is standard unless there is obvious surgical failure.

The conservative course is to heal up from the surgery and see what happens. It's entirely possible that you'll be in the majority group that never needs further treatment...even with your T3B. Take daily walks, eat well, and if 'little Dugalf' wakes up enough to be useful and you have a willing partner....USE IT! My surgeon told me the best place to rehab a penis is inside a vagina.

T3c here. I am most fortunate to live in a place where there are lots of very wealthy people so we have a top - notch medical system. When I was diagnosed I got the very best of cutting - edge therapy and current medical thought on dealing with PCa.

My first PSA blood test was 2 weeks after DaVinci RP. It was 0.2 so I flunked that test. The number should have been below 0.02 (undetectable) so my surgeon immediately put me on Firmagon ADT (there is no testosterone flare with that chem) as there were some "microscopic pieces of the cancer" left behind after the operation that were generating that PSA. I then went on with 2 years and 4 months of ADT (Lupron, then Eligard after 3 mo of Firmagon), which has kept my T around 2.5 ng/dl and my PSA "undetectable" at less than 0.02 ng/dl.

After 3 months of chemo I went in for 40 sessions of external beam radiation therapy.

Why?

My understanding is this: acinar adenocarcinoma stem cells live for about 3 years. The primary tumour has a bunch of those so they remove them 'as best' they can with surgery. PCa stem cells have 2 forms, a round stationary type that just sits, eats, gets bigger until it splits into 2 daughter cells, and a long stringy type that can move around forming transient attachments to surrounding tissues, push other cells aside, insert itself into blood vessels or other organs, travel to distant parts of the body, put down roots and change to the first type of stem cell. The second type cannot undergo mitosis to reproduce, it must change to the first type of stem cell to do that. The first type of cancer stem cell is like a beach ball and the second is like an amoeba. Both types of stem cell can change to the other type BUT they must have testosterone to do that. Take away the T and they cannot grow, move or reproduce.

After 3 months of ADT I got external beam radiation therapy. That raises the level of oxidants in all of the cells that get irradiated. The cellular bodies that neutralize oxidants and remove them from the cell so that they do not injure or kill it are called mitochondria. The more advanced a PCa cancer cell is on the Gleason scale, the fewer functional mitochondria the cell has to deal with those antioxidants, stem cells inclusive. The point is to assure that any live PCa cells have been sorely stressed sufficient to - if not kill them outright - to injure them sufficient to very much shorten their life span.

The progression made sense to me for my situation, starting with the logic of that first blood test 2 weeks after surgery.

Of course, as always, your mileage may vary.

Dugalf,

A few observations about Trailguy's experiences and how they may apply to your case.

His PSA test two weeks after his RP was too early to say anything definite about the results of his surgery, at least with the results he got from that test. PSA lingers in the blood with a half-life of two to three days. This means that with his pre-op PSA of 11 you would expect him to have something like 0.15 after two weeks. Also, when a surgery gets a bit messy there are sometimes bits of prostate tissue left behind that have been detached from their blood supply and will eventually die but which can linger long enough to confuse the issue with early PSA readings.

It is highly likely that his doctors had already decided on hormone therapy and radiation and his two-week PSA had little effect on their decision. My case was similar. My first post-op PSA was a detectable 0.01 at seven weeks (still earlyish) and my doctors' response was, in effect "That's nice. Drop your pants and bend over for your hormone shot. Here's your referral to the radiation oncologist."

What's different between you and trailguy, and between trailguy and me, is our Gleason scores. His description of the two types of prostate cancer cells was a description of two of the five grades used to characterize prostate cancer cells in the Gleason Grading System (Wikipedia Link). He was describing grade 3 and grade 4 cell types. His Gleason score of (4+3) means that the more-aggressive grade 4 cells predominate. This makes his risk a bit higher than yours since your (3+4) score means that the less-aggressive grade 3 cells are the predominant type.

He didn't mention Gleason grade 5 cells which are even more messed-up looking and even more aggressive. You and he, apparently didn't have any of those, which is good.

What your doctor proposes seems sensible for your Gleason score and surgical results. Even if radiation does turn out to be required they will need to wait to give you time to heal from the surgery and, hopefully, to regain continence. A lot will depend on you next PSA test at three months out. The value you will want to see is anything less than 0.03 and hopefully "undetectable".

We are all to young to have to be dealing with this. Since we have to anyways, it is good to learn as much as possible so as to make informed decisions.

So, incontinence has suddenly become a problem. It was good for the first two weeks post-op and has suddenly become a bit of a problem, particularly at sleep. Has anyone else had this experience?

Thank you!

Since you have confirmed SVI, my assumption is (and it's only an assumption) your doctor will recommend radiation at some point. I went through a period where I thought I might have SVI and my surgeon told me if it was confirmed after surgery he would recommend radiation as there is a 30% chance the lymph nodes are affected. Some sites say 50%. I decided against surgery and chose radiation instead as my primary treatment after I had a biopsy of the SV and it was negative.

The prognosis of SVI used to be poor, but in recent years treatments have improved significantly and the outlook is much improved.

Good luck to you.

Pretty early to tell what your results will be. I agree with Peter DA. It will take a good 3 months for the prostate tissue to get out of your system and then they can see what is left, if anything. Hopefully your surgeon cut wide enough.

I am a T3A so I have been on PSA tests every 3 months to see if there is any rise. I was told I had a 20% chance of recurrence within 10 years of my surgery.

Hopefully your 3 month PSA test will be undetectable.

Good luck, there will be plenty of time to worry, don't start yet.
Heh, easy for me to say, right?

Bill from Florida