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Thread: Packing List for Surgery ~10 hour drive away

  1. #21
    Experienced User
    Join Date
    Apr 2019
    Posts
    68
    Based on this one, and some of the articles it cites, we're looking at a likely upgrade on pathology. Tiny prostate +.5 PSA density (outside most study ranges) doesn't bode well.
    Wife Posting, Husband D.O.B. 1975
    2/2018 - routine physical PSA 15
    3/2018 - PSA 13
    4/2018 - PSA down to 11.6, free PSA, 18%
    6/2018 - PSA 10, free PSA 20%
    7/2018 - mp- MRI done, prostate volume =22cc, "inflammation consistent with prostititis"
    11/2018 - PSA 14, free PSA 11%,
    3/2019 - PSA 12, free PSA 17%, 2nd opinion on MRI = PI RADs 3 lesion
    4/2019 - Cognitive Fusion Biopsy
    5/12 cores positive
    4 Gleason 3+3
    1 Gleason 3+4 5% (Where PIRADs 3 lesion IDd)
    Decipher Biopsy score: .07 very low risk

    Bone scan negative
    MRI 6/19 said PIRADS 4 lesion, no definite EPE

    RRP 7/19 Final Path: pT3a
    G6 - 75-90%
    G7 (3+4) - 11-25%
    24mm tumor, 30% of prostate
    EPE+, BNI+, SM + (at bladder neck), LVI-, SVI -, PNI-, Nodes -
    Decipher Post RP score: .78, high risk

  2. #22
    Quote Originally Posted by AceVA View Post
    Based on this one, and some of the articles it cites, we're looking at a likely upgrade on pathology. Tiny prostate +.5 PSA density (outside most study ranges) doesn't bode well.
    It's possible, of course, but you're now prepared. IMO, a good result can be had by all if:

    (1) The path report confirms that the PCa, whatever the G score, was prostate-confined: no seminal vesicle invasion, no positive lymph nodes, no positive margins, and no extraprostatic (or extracapsular) extension (i.e., none of the four major negative findings).

    and

    (2) The first post-op PSA (at about 5-8 weeks or even longer) comes back as "essentially undetectable" on a less sensitive PSA test (e.g. <0.1) or, lower, e.g., <0.01 on a more sensitive one.

    If the above conditions hold, primary cancer treatment is over. This is, unfortunately, no guarantee of a PCa-less future; we all have to monitor our PSA after diagnosis, but it does mean you're starting off in the best place for your G score.

    As I've previously mentioned, for prostate-confined cancer (pT2), the latest TNM guidelines (8th edition) has done away with the a, b, and c subdivisions (according to lesion location within the prostate). It has been established that there is no correlation between where the lesions are in the prostate and outcomes. So my pT2c (bilateral involvement, RP in '17) would today be reported simply as pT2 by a lab using the latest guidelines.

    However, for percentage of the prostate involved by the cancer (a figure also reported in a standard path report), less is better as far as predicting better outcomes, as you might imagine. One study found that <7% (good) or >7% (less good) was a statistical marker (yes, I left out the = sign, because I don't remember which 7 gets it, not that it matters a lot )

    Whatever the outcome, if there is still concern after surgery because of a disappointing outcome, you can have a genomics test (e.g. Decipher) done on the removed tissue to estimate your cancer's likelihood of metastasizing (assuming any was left over after the RP).

    Djin
    Last edited by DjinTonic; 07-09-2019 at 09:30 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

  3. #23
    Senior User
    Join Date
    Nov 2018
    Posts
    243
    I get confused about the seminal vessel thing. When it showed on my 3T MRI the day before surgery that had invasion into one seminal vessel I was pretty down telling the doctor that from what I knew that was not good and cancer had spread and wouldn't be able to get it. He said we take out the seminal vessels anyway so should get it. Afterwards he said he didn't see any tissue that was left that obviously showed any cancer. Ask about the positive margins and he said kind of the same thing and also said that the margins may not mean anything. At my first post op consult and psa he said I was still considered high risk but as far as he was concerned at this point he considered me cancer free and would just watch it real close. So yeah pretty unnerving but just have to go on 3 months at a time.
    Last edited by nmguy; 07-10-2019 at 12:36 AM. Reason: Left word out

  4. #24
    Senior User
    Join Date
    Nov 2018
    Posts
    243
    It didn't attach my signature so here it is.
    DOB 1955
    63 at dx
    3/2018 PSA 4.05 DRE normal refer to URO small town
    10/2018 PSA 6.28 DRE normal
    Bx 11/2018 12 cores 3 pos 1 - 5% left mid 2 - 50% left base
    GS 3+4=7 T1c
    Appt Mayo Clinic Phoenix Az 1/4/2019
    Dr. Paul Andrews recommend
    MRI 2/27/2019 Mayo AZ
    RALP 2/28/2019 Mayo AZ Dr. Paul Andrews
    Path: GS 3+4=7, Tertiary Gleason Pattern none, Grade Group 2
    Tumor presents moderate to extensive volume mainly posterior
    portion of prostate. Largest tumor nodule measures 8 mm
    Prostate: 21g 3.5 x 3 x 3 cm
    EPE: Neg
    Bladder Neck Invasion: Neg
    Seminal Vesicle Invasion: Pos (left seminal vesicle)
    Margins: Pos left lateral base & central base 2mm focus each
    Lymph Nodes involved: 0
    Lymph Nodes Ex: 16
    Nerves spared right side only
    Path Staging (AJCC 8th Edition)
    Primary Tumor pT3b
    Regional lymph nodes: pNO
    Distant Metastasis: Mx
    Continence 99% 9 wks
    ED Present
    PSA 4/17/2019 <.10
    PSA 5/2/2019 <.007
    PSA 6/10/2019 <.10
    PSA 8/1/2019 <.007
    PSA 9/16/2019 <.10

  5. #25
    Quote Originally Posted by nmguy View Post
    It didn't attach my signature so here it is.
    Seminal vesicle invasion is a negative finding at RP. At its worst, the cancer can extend to either end, one being the tip of the SV, making it hard to remove completely; also, the cancer can spread from the SV to other adjacent tissue that's outside the prostate. However in most cases the seminal vesicles are usually entirely removed. So any cancer in them may have been entirely removed. However SVI+ is a statistical indicator of a more likely (but not certain) PSA increase in the future. The same goes for positive margins: they can be insignificant, especially if <3 mm. Until and unless BCR (a return of increasing PSA) occurs, you can have reason to believe the surgery did get all the cancer. So in addition to the number of negative findings, the extent of each also counts: EPE+ can be just a pinhole piercing of the capsule, SVI+ can be minimal, a margin could be an artifact or insignificant, etc.

    Your 2-month PSA was perfect. As you said, it's relax, and take it 3 months at a time for all us high-risk guys.

    Djin
    Last edited by DjinTonic; 07-10-2019 at 01:22 AM.
    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

  6. #26
    Experienced User
    Join Date
    Apr 2019
    Posts
    68
    Quote Originally Posted by DjinTonic View Post
    It's possible, of course, but you're now prepared. IMO, a good result can be had by all if:

    (1) The path report confirms that the PCa, whatever the G score, was prostate-confined: no seminal vesicle invasion, no positive lymph nodes, no positive margins, and no extraprostatic (or extracapsular) extension (i.e., none of the four major negative findings).

    and

    (2) The first post-op PSA (at about 5-8 weeks or even longer) comes back as "essentially undetectable" on a less sensitive PSA test (e.g. <0.1) or, lower, e.g., <0.01 on a more sensitive one.

    If the above conditions hold, primary cancer treatment is over. This is, unfortunately, no guarantee of a PCa-less future; we all have to monitor our PSA after diagnosis, but it does mean you're starting off in the best place for your G score.

    As I've previously mentioned, for prostate-confined cancer (pT2), the latest TNM guidelines (8th edition) has done away with the a, b, and c subdivisions (according to lesion location within the prostate). It has been established that there is no correlation between where the lesions are in the prostate and outcomes. So my pT2c (bilateral involvement, RP in '17) would today be reported simply as pT2 by a lab using the latest guidelines.

    However, for percentage of the prostate involved by the cancer (a figure also reported in a standard path report), less is better as far as predicting better outcomes, as you might imagine. One study found that <7% (good) or >7% (less good) was a statistical marker (yes, I left out the = sign, because I don't remember which 7 gets it, not that it matters a lot )

    Whatever the outcome, if there is still concern after surgery because of a disappointing outcome, you can have a genomics test (e.g. Decipher) done on the removed tissue to estimate your cancer's likelihood of metastasizing (assuming any was left over after the RP).

    Djin
    I appreciate your optimism! We got the decipher on the biopsy tissue, and it came back very low risk, but I've known his nomogram numbers are pretty bad all along. We will absolutely be getting decipher again post-surgery given his age. There's not a lot of 40 year DSS stats, which is what his lifespan should be, and I want every possible piece of information we can possibly get going forward.

    Given 45% of cores positive, and up to 80% core involvement (all right side), I'd guess we're dealing with a high volume of the prostate involved. Would seem the right side is at least 50% cancer.
    Wife Posting, Husband D.O.B. 1975
    2/2018 - routine physical PSA 15
    3/2018 - PSA 13
    4/2018 - PSA down to 11.6, free PSA, 18%
    6/2018 - PSA 10, free PSA 20%
    7/2018 - mp- MRI done, prostate volume =22cc, "inflammation consistent with prostititis"
    11/2018 - PSA 14, free PSA 11%,
    3/2019 - PSA 12, free PSA 17%, 2nd opinion on MRI = PI RADs 3 lesion
    4/2019 - Cognitive Fusion Biopsy
    5/12 cores positive
    4 Gleason 3+3
    1 Gleason 3+4 5% (Where PIRADs 3 lesion IDd)
    Decipher Biopsy score: .07 very low risk

    Bone scan negative
    MRI 6/19 said PIRADS 4 lesion, no definite EPE

    RRP 7/19 Final Path: pT3a
    G6 - 75-90%
    G7 (3+4) - 11-25%
    24mm tumor, 30% of prostate
    EPE+, BNI+, SM + (at bladder neck), LVI-, SVI -, PNI-, Nodes -
    Decipher Post RP score: .78, high risk

  7. #27
    Quote Originally Posted by AceVA View Post
    I appreciate your optimism! We got the decipher on the biopsy tissue, and it came back very low risk, but I've known his nomogram numbers are pretty bad all along. We will absolutely be getting decipher again post-surgery given his age. There's not a lot of 40 year DSS stats, which is what his lifespan should be, and I want every possible piece of information we can possibly get going forward.

    Given 45% of cores positive, and up to 80% core involvement (all right side), I'd guess we're dealing with a high volume of the prostate involved. Would seem the right side is at least 50% cancer.
    That Decipher result is very good news, indeed -- add it to your signature! Hopefully all the removed lymph nodes will be clear and, whatever the path findings local to the prostate, the cancer has not (and will not) metastasize. No one dies from prostate-confined cancer.

    Sit tight, keep your Go Kit by the door, and smile for the camera!

    Djin

  8. #28
    Quote Originally Posted by AceVA View Post
    I appreciate your optimism! We got the decipher on the biopsy tissue, and it came back very low risk, but I've known his nomogram numbers are pretty bad all along. We will absolutely be getting decipher again post-surgery given his age. There's not a lot of 40 year DSS stats, which is what his lifespan should be, and I want every possible piece of information we can possibly get going forward.

    Given 45% of cores positive, and up to 80% core involvement (all right side), I'd guess we're dealing with a high volume of the prostate involved. Would seem the right side is at least 50% cancer.
    Look at my signature. 6/12 cores ranging from 5-100% all left side. 10% of prostate involved.

    20-25% involvement seems to be the average on this forum. 50% would be double the average.
    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.

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

    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)

    ADT - 6/19 - 6/21
    ART - 8/19 - 9/19. (78 Gy, yes, I glow in the dark)

  9. #29
    I don't think you can make accurate estimates for the whole prostate based on percent cancer in cores. I had just 2 positive cores on one side, 5% and 50%. Yet my cancer was bilateral, but only 5% involvement. My uro explained that a great deal depends on geometry: the angle of the biopsy needle with respect to the lesion. With a cigar-or oval-shaped lesion you'll get a very high percentage if the needle is centered with the long access, and a small percentage if coming through perpendicularly. One paper described the spread of PCa out from the primary lesions as tendril-like.

    Djin
    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

 

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