My decision and path report

A couple of months ago I was asking for advice here on treatment options. I consulted two RO (HDBR and cyberknive) and a urologist/surgeon. Finally I decided to have surgery based in the surgeon experience (more than a thousand of manual LRPs, actually some of my friends were his patients) despite his personality, total lack of empaty and communication. I also were not happy with the idea to having an additional tretment for my enlarged prostate and with the lack of precise information, no pathological report, no early warning of recurrence, if I have chosen the radiation way. On the other hand I considered that maybe radiation was more effective in the case ECE was present, MRI showed some contacts with the capsule, but any choice have an uncertainty component.
Surgery was mostly uneventful, some pain (kind of spams or gas or both) that completely vanished after 12 hours. I still have occasional spams after urinating, but they are not too bad. The main incisions developed a couple of light seromas that I hope will heal by themselves. I have mild incontinence only when standing up or walking, but the pads get now 60% less in weight than the day the catheter was removed (200/500 g. per day).
Today I have got the pathological report. Contrary to what I thought most probable, it clearly remarks that there is not ECE and margins are clean (organ confined). But... it shows a big jump in grade from 3+3 to 5+3. Therefore, I think I made the right decision on my treatment (just by chance). I went to the mskcc nomogram and it predicts a specific survival of 99% in 15 years and a BRS of 60% in 10 years,which it does not seem too bad. Of course I understand this is based in a mskcc cohort and it is plain statistics. I would greatly appreciate your expert opinion about what can expect. First PSA in February.

Welcome to the other side. Your large prostrate size does reduce your chance of BCR.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3102877/[url]

"In agreement with previous reports (20, 21), we showed that men with smaller prostates were at a significantly higher risk of BCR. The reason for this remains unknown; however, many potential explanations exist. First, it has been suggested that men with smaller prostates may have lower levels of testosterone, which has been shown to correlate with more aggressive prostate cancer (22). Second, men with larger prostates had their tumors detected earlier because of PSA-driven biopsies resulting from PSA elevation from an enlarged gland. This lead-time bias would be expected to result in better outcomes (23). As shown in Table 1, the extra-prostatic group had a higher PSA than the organ-confined group. The PSA range was 3.7-95.8 ng/mL. Thus, a PSA-driven biopsy group that had a large portion of benign tissue is difficult to be included. Third, a tumor within a small prostate has to migrate a lesser distance to escape the prostatic capsule, as demonstrated by Yadav et al. (24), who showed that decreased prostate volume is a predictor of extra-prostatic extension. It is likely that a combination of these factors leads to a greater chance of BCR after treatment for men with smaller prostate volume. The most important finding in our study was obtained from the analysis of prostate volume stratified by pathologic T stage. Our data showed that prostate volume was not prognostic in the pT3 group."

jmadrid said...
...Today I have got the pathological report. Contrary to what I thought most probable, it clearly remarks that there is not ECE and margins are clean (organ confined). But... it shows a big jump in grade from 3+3 to 5+3. Therefore, I think I made the right decision on my treatment (just by chance). ....

And that's the advantage (so to speak) of surgery and a path report, you have a definite grading of the cancer from the excised tissue.

The G 5+3 is a very atypical reading and I wonder if it's worth getting some confirmation on that. I believe you're in Spain, so not sure what your options are. But if one of the goals of surgery was to have the definitive pathology, I would consider following up on that.

Congrats on making it through and I wish you continued success with the healing!

Thank you again for your well informed answers.
Yes, it is difficult to have a second opinion on a pathological report here in Spain. I understand 5+3 is very atypical. The report took three weeks to come, I wonder if they made some kind of verification. I took a look of the pathologist name in the internet and he seems to be a big name here (what does not warranty much).
My idea is to say goodbye to my urologist/surgeon, he did a good job avoiding margins but I do not like his clinical protocols. I have got a prescription for a simple PSA plus free PSA (???) analysis. It was given by his assistant, he was not today present. I will go to an oncology center for closer monitoring and advice.

Thank you TA,
I want to believe now that staging is more important than grading.
I revised the MSKCC nomogram (graphic). They assign many points to the G4 secondary pattern. This explains why 5+3 gives a better outcome than 4+4.
But probably the publications I have already read are right and 5+3 is more risky than 4+4.
I will try to find a good oncologist and wait for the results of a good PSA analysis in a couple of months.
According to what I know now, I guess that trusting in just a single primary radiation treatment for my case in the belief that grade was low would have been risky. Since tumor was organ confined I guess I made the right option.

I agree with others concerning the big change in your Gleason rating. It's not uncommon to hear of changes in Gleason scores following surgery. However, most who change report incremental changes such as 3+3 to 3+4 or to 4+3. A change like yours from 3+3 to 5+3 I think is very unusual. I can't imagine that the post surgical pathology is from the same tumor as the one found in your biopsy. My guess is the pathologist examined multiple sites as would be routine and one of the samples revealed far worse cancer tissue than the biopsy. To believe that the surgery pathologist simply disagreed with the biopsy pathologist is unimaginable. Whatever the reason I urge you to get a second opinion.