PC JUST DIAGNOSED

rpgilboy · New User Joined: 23 Jul 2009 Posts: 9

I am 67 yrs old diagnosed last week with PC after 5 cancer of 28 core saturation biopsy. 10 cores last Sept negative. DRE normal, PSA 5.6.
two gleason 8, 2 gleason 7 and one gleason 6. Am debating on open or robitic and what prognosis might be. Bone scan normal.

Replicant · Moderator Joined: 01 Nov 2006 Posts: 744

The Partin tables show, with Gleason 8-10, PSA 5.6, stage T1c, your odds of organ confined disease is 55% (range 46-64). Your odds of extraprostatic extension: 32%. Odds of seminal vesicle invasion: 10%. Odds of lymph node involvement: 3%.
http://urology.jhu.edu/prostate/partintables.php

UroPredict, by Bostwick Labs (a leading prostate pathology lab) shows a 37% chance of organ confined disease, 63% chance of extraprostatic extension (this is where the cancer penetrates the capsule), and a 16% chance of seminal vesicle involvement. http://www.bostwicklaboratories.com/uropredict/uropredict.aspx

The Han tables ( http://urology.jhu.edu/prostate/hanTables.php ) show that if you have a prostatectomy, your odds of a recurrence within 5 years: 17%. Within 10 years: 29%.

These are all rough predictions, and the Partin tables, for example, were based on results from one of the world's best hospitals for prostate surgery, by some of the world's best surgeons, so your experience may very well be different. And of course, you are not a statistic.

As for robotic or open, I would go for the best surgeon you can, and go with the surgery he is most experienced in. I had a very good surgeon, but he was just learning the robot, and I think I would have been better off having him do the traditional surgery. If you have robotic, make sure the surgeon has done a lot of them--at minimum 100 procedures, in my opinion, and find out if he's getting good results in terms of surgical margins. You want to hear "negative margins" meaning there was no cancer at the cut edge of the removed tissue.

I've seen several postings by guys who had the open surgery, and the recovery experiences they reported didn't seem much different from the robotic ones. There are advantages to both forms of surgery--robotic offers at least the promise of less post-surgery pain, faster recovery, etc. while open surgery allows tactile feedback (the surgeon can get in there and feel the tissues.)

Go for the doctor over the technique, in other words. It's also a good idea to have it done in a hospital where lots of the surgeries are performed. This could be your one big chance to wipe out the cancer, and you don't want to go with a doctor on the basis of a hunch.

Before you decide for sure on surgery, make sure you understand the pros and cons of the other treatment modalities, like seeds, protons, traditional radiation (i.e. IMRT or IGRT).

Best of luck to you.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

johnT · Senior User Joined: 27 Apr 2009 Posts: 176

It was good than you got a 28 core biopsy, but it would be better if you spent some extra time getting your cancer staged as it may affect your treatment options.
The location of the tumor is of importance because if it is a transition zone tumor, near the seminal vessels or the tumor has already penetrated the capsul it may affect what type of treatment you choose for all of these surgery would not be the best option. An endo rectal MRIS with a Telsa 3 machine or a color doppler ultrasound can tell you a lot. Other tests like a PAP or prolidgy analysis can indicate if the PC has already started to spread. A 2nd opinion from a noted Prostate Oncologist is well worth the time and money. Personally I wouldn't get any treatment until I had an unbiased 2nd opinion and MRIS or color doppler scans to back up the recommendation.

JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

rpgilboy · New User Joined: 23 Jul 2009 Posts: 9

Met with surgeon at Mayo Clinic and decided to have RRP because I had two gleason 8 and 2 gleason 7 out of 28 core biopsy. I thought he said there was no perineal (sp?) involvement. Is it possible to detect perineal involvement on a biopsy alone. What about lymph node involvement?

johnT · Senior User Joined: 27 Apr 2009 Posts: 176

The best thing anyone can do is guess. See Replicant's above post. This is the best guess given your stats without futher testing.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

Replicant · Moderator Joined: 01 Nov 2006 Posts: 744

He probably said "perineural". There are nerves inside the prostate gland, more of them near the edge.

Perineural invasion (PNI) is a common thing on biopsies. It's not great, but it doesn't mean the person is incurable, either. You don't like to see it, because it means you have cancer near the outer edge of the prostate, and perhaps its penetrated the capsule.

So, it's in your favor that it was not found on your biopsy.

The stats give you a rough idea of your chances, but there are no guarantees. Even if the surgeon tells you everything went great, you will have to monitor your PSA closely for some time, and on a regular basis for most of the rest of your life.

Best wishes on the surgery. When is it scheduled?
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T2c, NXMX, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 (and thereafter) <0.1
http://pcabefore50.blogspot.com

rpgilboy · New User Joined: 23 Jul 2009 Posts: 9

Yes, he probably said perineural. Talked to the urologist physician assistant yesterday and he said Dr. Igel's patients at Mayo Clinic have not experienced a great deal of incontinence because the surgeon uses some type of sheath (does that sound right??). Also said Dr. Igel has done over 1000 RPPs. Surgery is scheduled for 13 August. Thanks for the information and your thoughts. Rich

Skippy · Regular Joined: 24 Apr 2009 Posts: 10

Go for it rpgilboy. On open vs. laparoscopic/robotically assisted RRP I can only repeat what my very experienced (about 1200 open prostatectomies) Australian surgeon had said.

He said he focused since the inception of his professional career on perfecting his technique of open RRP. The technique is apparently difficult to learn, and decidly non-trivial, particularly when sparing the neurovascular bundles, as my doctor often does.

In his opinion, while laparoscopy in general and robotically assisted laparoscopy technique in particular do have their rightful place in prostate surgery, they are far from the magic bullet.

Their popularity for patients is shorter recovery and less post-op pain. Their popularity for surgeons and hospitals is the higher throughput of patients and faster turnover in expensive facilities. He said that since money has long lost the shine of novelty for him (how many Porsches can you drive at the same time, as he puts it) he has had doubts on the ethics of putting the first 200 or so patients at risk of suboptimal outcomes while learning the new and unfamiliar technique.

Have a look here at an article by a British surgeon describing in dry scientific terms what it takes to become proficient in laparoscopic RRP.

http://www.ncbi.nlm.nih.gov/pubmed/19021612

BJU Int. 2009 May;103(9):1224-30. Epub 2008 Nov 20.
The first 1000 cases of laparoscopic radical prostatectomy in the UK: evidence of multiple 'learning curves'.
Eden CG, Neill MG, Louie-Johnsun MW.
Department of Urology, The Royal Surrey County Hospital, Guildford, UK.

I have trusted my Australian doc's view, and so far (21 months from my RRP) I do not have any reason whatsoever to question his judgment.
_________________
Skippy (Australia): age at dx 53, PSA 6.0, biopsy, dx Aug 2007: T2aNxMx Gleason 7 (3+4); open RRP + PLND 01Nov2007, both bundles spared, pathology pT2aN0Mx, Gl.7 (3+4), margins negative, no perineural involvement, lymph nodes clean. PSA since surgery undetectable (below 0.04). Continence back to 100% of pre-op state within 2 mths of surgery; erection initially nil, 30% at 12 months, 70% at 18 months with regular tadalafil + sildenafil before practical attempts.

rpgilboy · New User Joined: 23 Jul 2009 Posts: 9

Skippy, thanks for the encouragement and the link to the very interesting article on LRR proficiency - wow, a big learning curve for surgeons. I am now more convinced than ever that RRP is the way to go if opting for surgery with the best possible results.

John M · Experienced user Joined: 27 Jul 2009 Posts: 59

I had almost exactly the same experience in Seattle as Skippy in Australia. Very experienced surgeon in the open operation, doesn't do the robotic surgery for exactly the same reason Skippy discussed so clearly. Nerves spared. Some pain the first day or two, out of hospital in 48 hr. Never had any incontinence. It's only been 2 months, but I seem to be on a similar recovery curve for erectile function...about 40-50% so far. Not that everyone will have the same experience, but it's a good idea not to be part of the "learning curve".

John
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John

srtimmons · Posted: Fri Jul 31, 2009 1:46 pm Post subject: Robotic Surgery

I had my robotic surgery on July 20th and am glad i went that route. I have had almost no pain at all and was up walking the evening of the surgery. The catheter was biggest issue and it was removed in 7 days as planned.

I am also very happy that I have about 50% control on my urination. I expected to have no control for several months.

I start the Viagra and Muse this week-end and hopefully, will start recovering from the ED caused by the surgery (I had one nerve bundle removed and replaced with a graft)

Wishing you all the best in your decision.

rpgilboy · New User Joined: 23 Jul 2009 Posts: 9

I would probably opted for the robotic except for the two gleason 8 cores. Dr. Walsh at Johns Hopkins will not do robotic on high grade cancers. Heard on tv that Senator Dodd of Connecticut announced he was diagnosed with early stage PC today. Maybe he can encourage more spending on research etc. on PC.

Does the pre-prostatectomy PSA have considerable bearing on post surgery process?

Skippy · Regular Joined: 24 Apr 2009 Posts: 10

"Does the pre-prostatectomy PSA have considerable bearing on post surgery process?"

AFAIK, not as such, but there may be RP cases when high PSA is accompanied by high Gleason, which is taken as a much clearer predictor. The treating doctor may then opt for adjuvant radiotherapy after RP.

The higher the PSA, the higher the suspicion that the cancer has spread. Many surgeons will not operate at all at PSA>20 as they believe it a wasted effort - while nothing is seen yet in imaging, micro-metastases could be already present in lymph nodes. Statistically, a three-digit PSA (>100) is taken as a virtually certain systemic cancer.

This is in my view a fine line for the doctor's professional judgment, and a bit of a chicken and egg issue too, because just about the only way to guarantee that prostate cancer has NOT spread beyond the capsule and/or to the regional lymph nodes is to do detailed pathology examination of the removed prostate, seminal vesicles and lymph nodes removed in the same operation as the prostate. So, at the end of the day, this may boil down to the surgeon's propensity to wager or not wager that the cancer has not spread.

For patients with PSA between about 10 and 99, with no metastatic spread symptoms seen in the imagery (CT, TRUS, MRI) and negative bone scan, I guess the operate/not operate decision would probably boil down to whether the treating doctor has more faith in statistics or his own independent judgment.

I have never heard of anyone successfully persuading a urological surgeon to operate at PSA 50 or above. I have heard of cases of doctors sporadically refusing surgery above PSA 10, and generally refusing surgery above 20. The generally accepted cutoff for RP eligibility appears to be around 20.

Anyone with any views on this one?
_________________
Skippy (Australia): age at dx 53, PSA 6.0, biopsy, dx Aug 2007: T2aNxMx Gleason 7 (3+4); open RRP + PLND 01Nov2007, both bundles spared, pathology pT2aN0Mx, Gl.7 (3+4), margins negative, no perineural involvement, lymph nodes clean. PSA since surgery undetectable (below 0.04). Continence back to 100% of pre-op state within 2 mths of surgery; erection initially nil, 30% at 12 months, 70% at 18 months with regular tadalafil + sildenafil before practical attempts.

rpgilboy · New User Joined: 23 Jul 2009 Posts: 9

I was talking to a urologist (not one at Mayo where I am scheduled to have surgery) and told him about my PC diagnosis. He said that five out of 28 cores with PC a rather low percentage (and good) but having two gleason 8 on two cores in the right lateral peripheral zone and two gleason 7 high in the right transition zone with basically all negative in between unusual. Does anyone have any information on this subject.

johnT · Senior User Joined: 27 Apr 2009 Posts: 176

Skippy,

The Combidex MRI can identify lymph node PC with a 96% accurracy rate which is far better than surgical removal and dissection of the lymphnodes. Any PSA over 20 is highly indicative of lymphnode involvement; the exception is if you have a transition zone tumor which can give PSA readings of up to 300 and still be localized.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

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