Seeing the Surgeon Tomorrow Any Questions to Ask?

Travelingman

Hello again everyone. I haven't made a post in a couple of months. My 4th biopsy in June found cancer in one core. My wife & I just took a 6 week trip out west to see the country & I went to my urologist today. Thanks to all the excellent posts on this forum & a couple of books, I feel I am closer to making a decision on treatment. Initially my Urologist recommended radiation for me with surgery as a close second. Today I asked about watchful waiiting. He told me that he would be comfortable in my case with this approach since I am the type who would come in every 3 months for a DRE & PSA & would go for the required biopsies every few months. He did stress though that there is a window of oportunity before my cancer might spread. With a G6 & cancer in 5% of only one core, I would feel comfortable with WW if it weren't for my 18 PSA which was only 12 in December of 2008. Keeping in mind that my PSA was 6.0 in 2005 & 3.4 in 2001, he feels that my high PSA is a result of something other than cancer (such as the the health of my prostate). At any rate, I feel it's time to see the surgeon & I'm going tomorrow morning. Other than the normal things to ask (experience, etc.) do any of you have any suggestions of questions to ask keeping in mind my history whhich is in my signature? Questions such as sparing my nerve bundles, the sphincter in my bladder, etc. At 58 I don't want to overtreat my cancer but also don't want to fail to treat a problem that might be wose than the biposy shows.
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

Travelling man,
Your PSA of 18 does not correllate with a G6 5% tumor. Before I would receive any treatment I would find out why my psa is so high. You have to keep searching until you find the reason. A g6 tumor creates X amount of PSA for every cc of volume and it certainly isn't 18; more like 3-5. The extra PSA is coming from somewhere and you need to know where and why. It may take some detective work and it is definately out of the skill set of a surgeon or urologist. I would see a good prostate oncologist.
Other than that, a G6 5%, is most likely not a tumor at all, but indolant cancer cluster that would never hurt you; but your PSA of 18 is definately a concern and most certainly not indicative of what your biopsy shows. I had two 2nd opinions from prostate cancer speceialists for a G6 less than 5% and both said they would never treat it.
Some reasons for a hgh psa and low gleason/core:
1. Infection
2. Transition zone tumor not picked up on biopsy.
3. Micro Mets.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

Travelingman

[quote="johnT"]Travelling man,
Your PSA of 18 does not correllate with a G6 5% tumor. Before I would receive any treatment I would find out why my psa is so high. You have to keep searching until you find the reason. A g6 tumor creates X amount of PSA for every cc of volume and it certainly isn't 18; more like 3-5. The extra PSA is coming from somewhere and you need to know where and why. It may take some detective work and it is definately out of the skill set of a surgeon or urologist. I would see a good prostate oncologist.
Other than that, a G6 5%, is most likely not a tumor at all, but indolant cancer cluster that would never hurt you; but your PSA of 18 is definately a concern and most certainly not indicative of what your biopsy shows. I had two 2nd opinions from prostate cancer speceialists for a G6 less than 5% and both said they would never treat it.
Some reasons for a hgh psa and low gleason/core:
1. Infection
2. Transition zone tumor not picked up on biopsy.
3. Micro Mets.
JohnT[/quote]

In your case, didn't ypu have basically the same info to go on? As I read it, you had a biopsy of a G6 5% core & a PSA of 40 & you actually had a tumor which needed treatment of seeds & IMRT. Was your tumor a Transistion Zone tumor? If I were suffering from an infection, would that show up in my urine or how would it be diagnosed? My prostate is only slightly enlarged. Please help me with one other item. What are micro mets? Please forgive the tone of my response, I don't mean to be disrespectful but I am really confused.
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

Travelingman · Posted: Thu Oct 08, 2009 4:34 pm Post subject: Additional Info for John T

John, Another reason for my Urologist feeling it's not an infection is that my PSA history is as follows:
December 1992 PSA 1.3
December 1999 PSA 3.0
March 2001 PSA 3.4
December 2005 PSA 6.0
November 2006 PSA 9.3
December 2007 PSA 9.9
December 2008 PSA 13.2
April 2009 PSA 18.0

It seems improbable that I would have an infection for that long a period but I am open to your thouights as well as any others. This whole process is like swimming underwater through mud. No one including my Doctors have a definitive answer. This seems to be a common thread in Prostate Cancer!
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

Putt · Regular Joined: 04 Aug 2009 Posts: 36 Location: Kansas

How many cores were taken during the biopsy? Did you get a second opinion of the results? I agree, with your level of PSA, something has been missed.

You are not at a stage in which action must be taken immediately, however, I would start getting agressive seeking opinions from others, including a Oncologist who specializes in PC.
_________________
PSA at Dx 105 at age 68, 4/04. ADT, RRP, 5/04. Gleason 4+5=9, Staged pT3c N0 MX, 3D rad, 40 treatments, 8/04. PSA 1/05 <0.01. ADT till 7/07. PSA 0.03 12/08, 0.07 4/09, 0.13 8/09, 0.19 12/09. Will start ADT3 after PSA reaches 1.2.

srtimmons · Posted: Thu Oct 08, 2009 5:30 pm Post subject: PSA 18

Your PSA of 18 is troublesome and needs immediate attention. posthaste. I agree with seeing a prostate oncologist for a 2nd opinion. Surgery is likely the most prudent path, but get more facts in. I would not recommed watchful waiting with a PSA of 18. IMOP.

GL and keep us posted.
_________________
Age 58
Dx 6/15/2009; PSA 7.1; 7/12 cores positive; Gleason 6 (3+3) and 7 (3+4); PNI observed. Bone Scan and CT scan negative.
Robotic RP 7/20/2009

Path report 8/11/2009 - clean margins, negative lymph nodes, negative seminal vesicles, Gleason 3+4, Stage T2c; 15% of prostate involved; NoMx.

PSA .006 September 2009
PSA .005 November 2009
PSA .005 February 2010

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

Travelling man,
I was basically in the same position you are. My 12th biopsy found a g6 5% and I was interviewing surgeons when my wife's doctor insisted I should see a prostate oncologist 1st. He was the one who said my stats didn't make sense and that my PSA history indicated a more serious cancer than the biopsy showed. He gave me a PCA3 test and a PAP test and sent me to a specialist who does color doppler ultrasound biopsies. It was that biopsy that found a large transition zone tumor that possibly could have generated that high of a psa, but to be sure I went to Holland for a Combdex MRI that came up clear for lymphnode matastis.
One of the things the oncologist stressed is that all the numbers have to add up before you make a DX. If they don't you have to eliminate all the possibilities one by one; that's how he approached my case.
He and the specialist who gave me the color doppler said they would never treat an individual with a G6 less than 5%. The color doppler and another biopsy of the area couldn't find any PC in the area the 12th biopsy found it. They said it is common to pick up indolant cancer clusters on biopsies and they are not tumors and most likely will never turn into tumors.
Mico mets is associated with a high PSA; what it means is that PC cells have escaped the prostate and are growing elsewhere, mainly in the lymphnodes.
Infections can last a long time; but they usually manifest themselves in a quickly rising and falling PSA. A steady upward increase in PSA is indicative of PC.
What I have found is that most urologists and surgeons only understand PC from a perspective of a surgeon which is mailily a mechanical view, and don't look at it from a biological cell level like an oncologist. An oncologist understand how the PC grows and spreads and how it manifests itself while doing this. This is a skill that urologists, surgeons and radiologists just don't have.
I'm not suggesting that your case is like mine; but that your numbers don't add up and until they do you should keep asking questons.
Johnt
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

Travelingman

Thanks to everyone for the responses. I will see what te surgeon thinks tomorrow & keep you all up to date. It is the high PSA which just doesn't correlate with the other factors.
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

Travelingman · Posted: Sat Oct 10, 2009 5:25 pm Post subject: Made A Decision

Yesterday I spent over an hour discussing my situation with a surgeon. I have decided to go ahead with the surgery & I want to post my reasons for doing so & am interested in any reactions to my decision & thought process. First I want to thank John T & Srtimmons for their input. The surgeon feels that if it were not for the PSA of 18, the fact that it has continued to rise & now seems to be accelerating in it's increases & the fact that my father died of prostate cancer, then WW would be acceptable. We went through all of the possible scenarios. His feeling is that many people go through a long process of seeing many different doctors yet end up back at the place that they started. My age, excellent health, & relatively low cancer volume are all factors in favor of treatment now. I feel surgery is the best option since I still can go for radiation if needed in the future. If I were to wait for a few years & then have to face treatment, then I might have missed the window of opportunity of removing the cancer before it can spread beyond my prostate. In addition, the older I am when treated, the more likely I might face complications & barriers to recovery. Dr. Ferlize worked under Dr. David Lee at the University of Pennsylvania for a year of doing nothing but robotic surgeries of the prostate. He has performed over 120 operations after leaving Dr. Lee & my local hospital has the DaVinci sytem. John T., your situation, in particular, was an important factor in my decision making. You were told everything from your cancer being indolant to a major transitional tumor, if I read your remarks properly. You ended up going through a lot of sophisticated tests & even went to Holland for consultations. I do not have those resources available to me. In addition, I feel that dealing with the side effects of surgery are a fair tradeoff allowing me to be there for my wife & potentially going through the awfull pain my father endured when his cancer traveled to his bones. As I see it, the worst thing that can happen, having a pathologist report that my cancer is small & totally confined to my prostate is acceptable when I think that the other end of the spectrum is continuing to wonder exactly what the cause of this high PSA is & missing the window of opportunity.

I look forward to reading the feedback from you men who have gone through so much yet are willing to share your experiences with the rest of us. Thank you all for taking the time to help us.
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

srtimmons · Posted: Sat Oct 10, 2009 8:29 pm Post subject: Good luck

Travellingman - good luck with your surgery. I did not realize that your father died of PCa, which is even more the reason to get this removed for good. At least with surgery you'll get a path report of the entire organ and they can see if there is any spread to the lymph nodes or seminal vesicles. That is important to know for sure.

GL and keep us informed. If you want to discuss your surgery, you can call me at 713-806-3720 anytime. I'll share my expereince for my July 20th RRP.

Steve
_________________
Age 58
Dx 6/15/2009; PSA 7.1; 7/12 cores positive; Gleason 6 (3+3) and 7 (3+4); PNI observed. Bone Scan and CT scan negative.
Robotic RP 7/20/2009

Path report 8/11/2009 - clean margins, negative lymph nodes, negative seminal vesicles, Gleason 3+4, Stage T2c; 15% of prostate involved; NoMx.

PSA .006 September 2009
PSA .005 November 2009
PSA .005 February 2010

Travelingman · Posted: Sun Oct 11, 2009 5:24 am Post subject: Re: Good luck

[quote="srtimmons"]Travellingman - good luck with your surgery. I did not realize that your father died of PCa, which is even more the reason to get this removed for good. At least with surgery you'll get a path report of the entire organ and they can see if there is any spread to the lymph nodes or seminal vesicles. That is important to know for sure.

GL and keep us informed. If you want to discuss your surgery, you can call me at 713-806-3720 anytime. I'll share my expereince for my July 20th RRP.

Steve[/quote]
Steve,

I will call you. What time zone are you in?

Ray
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

srtimmons · Posted: Sun Oct 11, 2009 8:26 am Post subject: Central

I'm in central time; Houston.
_________________
Age 58
Dx 6/15/2009; PSA 7.1; 7/12 cores positive; Gleason 6 (3+3) and 7 (3+4); PNI observed. Bone Scan and CT scan negative.
Robotic RP 7/20/2009

Path report 8/11/2009 - clean margins, negative lymph nodes, negative seminal vesicles, Gleason 3+4, Stage T2c; 15% of prostate involved; NoMx.

PSA .006 September 2009
PSA .005 November 2009
PSA .005 February 2010

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

Travellingman,
Good luck with your surgery and keep us posted.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

Travelingman

[quote="johnT"]Travellingman,
Good luck with your surgery and keep us posted.
JohnT[/quote]

Thank you John, you were very instrumental in helping to make up my mind to do the surgery. I appreciate your honesty!
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

Travelingman

[quote="johnT"]Travelling man,
Your PSA of 18 does not correllate with a G6 5% tumor. Before I would receive any treatment I would find out why my psa is so high. You have to keep searching until you find the reason. A g6 tumor creates X amount of PSA for every cc of volume and it certainly isn't 18; more like 3-5. The extra PSA is coming from somewhere and you need to know where and why. It may take some detective work and it is definately out of the skill set of a surgeon or urologist. I would see a good prostate oncologist.
Other than that, a G6 5%, is most likely not a tumor at all, but indolant cancer cluster that would never hurt you; but your PSA of 18 is definately a concern and most certainly not indicative of what your biopsy shows. I had two 2nd opinions from prostate cancer speceialists for a G6 less than 5% and both said they would never treat it.
Some reasons for a hgh psa and low gleason/core:
1. Infection
2. Transition zone tumor not picked up on biopsy.
3. Micro Mets.
JohnT[/quote]

John T, You were right. I had the surgery last Monday & got pathology today. Biopsy showed 5% of 1 core on the 4th biopsy. Pathology from surgery showed 30% of prostate had cancer with right & left lobes involved. It is really amazing how inaccurate biopsies are. If I had gone WW, I might be dealing with a much worse situation.
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

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