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Thread: Gleason score of 9... what can we expect?

  1. #11
    Regular User
    Join Date
    May 2017
    Posts
    44
    Hi Smash,

    Looks like you've started a virtual G9 dog pile!

    Sorry you needed to join us on your fathers behalf. Your note could have been written by my daughter, if it were 3 years earlier. I don't have much to add beyond the solid advice the FB's have already provided. Hopefully you've figured out how to read our signatures and can compare to your dads situation. Based on the information you've provided, it seems you've caught this early which is great news!

    If you have any additional questions, please let us know. As you can hopefully see, many of us can relate to your situation.

    Best of luck to you and your dad!
    Age at DX: 58
    PSA: 4.9
    Positive DRE
    Biopsy: 12/7/15
    Left Mid
    Adenocarcinoma 1/12 cores (45%)
    Gleason 4+3=7, CT abdomen, bone scan negative
    RALP 1/27/16 at CINJ/RWJ (New Brunswick, NJ)
    Surgeon: Dr Isaac Kim (1400+ procedures, highly recommend)
    Final Pathology: 2/1/16
    7 lymph nodes, seminal vesicles negative
    Postero-lateral (neurovascular bundle) margin involved by invasive carcinoma
    Gleason score 5+4=9 with intraductal component
    Primary tumor pT2: organ confined, high grade PIN
    Four post-op exams: PSA <0.01

  2. #12
    Newbie New User
    Join Date
    Apr 2019
    Posts
    2
    Thank you so much everyone for the helpful information and positive replies. I didn't know that I'd even had any responses as the email notifications went to a different folder in my inbox so I am just now coming back to this.

    I wish I had seen some of the responses earlier so we could have asked about the genomic testing. My dad went back in for his first post op PSA test at the end of April and it had not gone back to zero like we were hoping. At the time it was .02 and the doctor asked him to come back for another test 30 days out at which point his PSA had risen to .07. Now the doctor states he wants to start him on hormone therapy and then radiation.

    My dad is quite depressed at the moment, he isn't optimistic about the therapies and feels like it isn't even worth doing them. I think the doctor is being vague and not giving him any indication one way or the other, so in his opinion he feels like the treatments won't work and they are just buying him a little bit of time. But from what I've read here it seems that there is definitely still hope. He has mentioned possibly seeking a second opinion and while I'm encouraging him to start treatment right away, I have also offered to set him up with an appointment at a hospital in Seattle, which is a couple states away from him but they are a good hospital with claims of having a top Prostate Cancer program in the nation.

    I am also encouraging some dietary changes based on studies that I've come across and hoping that with these things combined we can get the cancer under control. But I'm still learning and it's all quite overwhelming. Again, thank you for your support and kind words.


    I was able to get a copy of the pathology report which stated the following:

    Right pelvic lymph nodes, dissection:
    6 lymph nodes with no evidence of malignancy

    Left pelvic lymph nodes, dissection:
    6 lymph nodes with no evidence of malignancy

    Prostate, radical prostatectomy:
    Prostatic adenocarcinoma Gleason grade 4+5=9 with extensive lymphovascular invasion, or extraprostatic extension, and seminal vesicle involvement.

    Grade Group: 5

    Estimated percentage of prostate involved by tumor: 45%

    Tumor Size: 2.7cm (left side)

    Extraprostatic extension: identified in several foci from the left superior gland. The foci range in size from 0.15 to 0.6 in greatest dimension

    Urinary bladder neck invasion: Not identified

    Seminal Vesicle Invasion: Present in the left seminal vesicle

    Margins: the surgical margins are free of tumor

    Perineural invasion: Present

  3. #13
    Hi Smasherie,

    Welcome back! Please keep in mind that we are not doctors! As you not doubt have surmised, this is locally advanced disease: a very large involvement of G9 (4+5) with multifocal EPE+ and SVI+. The good news is that the lymph nodes were all negative (had they known it was G9 going into surgery, they might have removed and examined a few more nodes, but that's not of great import). The surgical margins were also negative, and, as in my case, having Gleason 9 (4+5) is better than having G9 (5+4)

    Did your dad have a bone scan? If they suspected something like G7 (3+4) prior to surgery, perhaps not, in which case his doc will probably order one. Radiation and hormone treatment, alone or in combo, are pretty much standard of care for Gleason 9 men who have at least one adverse finding in their post-op path report. This would be true even if his post-op PSA were low and stable, which it appears not to be. (See Post #2).

    My dad is quite depressed at the moment, he isn't optimistic about the therapies and feels like it isn't even worth doing them. I think the doctor is being vague and not giving him any indication one way or the other, so in his opinion he feels like the treatments won't work and they are just buying him a little bit of time.
    That is something you and other family members can work on! The doctor may have been "thinking aloud" about treatment options and not have had his mind made up. There is no reason for your dad to have a sell-the-farm mindset. He will likely be around for a long time. You may want to get a 2nd opinion at a center of excellence in any case (or change his care team), but most certainly if his docs don't come up with a definite treatment plan, answer all your questions, and change their attitude. I think that seeing his PSA come down after further treatment will improve his mood. Although PSA is only a rough indicator of PCa likelihood before treatment, after a RP, PSA becomes an excellent tool for monitoring the effectiveness of treatments.

    Men do not die from non-metastatic prostate cancer, and while men with mPCa aren't cured, the disease can be kept under control in many cases. As D'Amico said in the research I mentioned earlier, men in your dad's category should be told that the upcoming RT and/or HT after surgery is an integral part of treating high-risk PCa. The first aim of further treatment is to wipe out any remaining cancer cells and prevent metastases. We now know that high-Gleason PCa is not always associated with a high risk of metastases. (Genomic testing of his RP tissue can be done at any time if it's thought it would be helpful.)

    A good diet, exercise, and a positive outlook are important!

    Keep us posted -- let's see what other Forum brothers have to say.

    Djin
    Last edited by DjinTonic; 06-13-2019 at 09:31 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day check)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  4. #14
    Negative lymph nodes is certainly a good omen for your dad, as well as the negative surgical margins.

    But he does have a high risk cancer, and most doctors are going to be alert to small PSA increases and aggressive in response. 0.07 is still a very low PSA score, and the doctors definitely think they have a good chance for a cure or they wouldn't be prescribing this aggressive treatment plan.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3, PSA test 7/2019 2.0


    DOB 1956, in Pittsburgh, USA

  5. #15
    45% of prostate involved by tumor +ECE + PNI + SVI. Negative margins with that pathology is a credit to your father’s surgeon.
    Last edited by Duck2; 06-18-2019 at 04:27 AM.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative.

    3/6/19. Pathology - Grade Group 4 with Intraductal Carcinoma
    T3aNO, GS8, 21 mm unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., +LVI, + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk.

    PSA 3/27/19 03 (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)
    9/10/2019. <.02. (198 days)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  6. #16
    Quote Originally Posted by Smasherie View Post
    My dad is quite depressed at the moment, he isn't optimistic about the therapies and feels like it isn't even worth doing them.
    Sorry to hear about your dad's pathology and rising PSA. A forum brother was recently prescribed Venlafaxine as an SNRI anti-depressant that also lessens some of the side effects of hormone therapy. If it's of interest you could also calculate the probability of successful radiation treatment here.
    --------------
    DOB 1965
    PM me for PSA graphing service & detailed story
    PSA 6.8 11/17
    PSA 7.5 04/18
    MRI 05/18 inconclusive, PI-RADS3?
    PSA 11.8 01/19
    PSA 10.1 02/19
    12 core random biopsy 02/19 (4+3)=7 suspicion of vascular invasion, grade 4 cribriform pattern, no PTEN loss
    Bone scan negative 04/19
    PSA 13.3 04/01/19 pre-surgery significant urinal symptoms and some ED
    RRP 04/04/19
    pT2c pN0 (0 of 7 lymph nodes positive) pL0 pV0 R0(local) Pn1
    Perineural growth predominantly on right hand side, tumour diameter 15mm 90% G4 10% G3
    Prostatic parenchyma with glandular hyperplasia and chronic granular, partly purulent inflammation.
    PSA 0.14 04/30/19
    PSA 0.02 05/13/19
    PSA 0.008 06/04/19

  7. #17
    Quote Originally Posted by KarlEmagne View Post
    Sorry to hear about your dad's pathology and rising PSA. A forum brother was recently prescribed Venlafaxine as an SNRI anti-depressant that also lessens some of the side effects of hormone therapy. If it's of interest you could also calculate the probability of successful radiation treatment here.
    Or here. Generally you will find the odds of being BCR free at 10 years is 50%. Radiation increases chance of being BCR free at 10 years to 82%. Certainly worth the treatment.

    http://riskcalc.org/ProstateCancerPr...Prostatectomy/

    It may not apply to your situation, but it gives the advantage of treatment.
    Last edited by Duck2; 06-18-2019 at 04:30 AM.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative.

    3/6/19. Pathology - Grade Group 4 with Intraductal Carcinoma
    T3aNO, GS8, 21 mm unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., +LVI, + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk.

    PSA 3/27/19 03 (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)
    9/10/2019. <.02. (198 days)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

 

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