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Thread: High volume G6 & Bladder Neck Invasion (& update)

  1. #1
    Experienced User
    Join Date
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    High volume G6 & Bladder Neck Invasion (& update)

    Seems like there's a few of us active right now with this pathology - and interestingly all younger men too IIRC.

    This article is one of the best I've found yet, and perfectly describes my husband's issue - a very large transition zone tumor that invaded the bladder neck: https://onlinelibrary.wiley.com/doi/...1111/bju.13173

    Conclusions: PSA recurrence in patients with histologically confirmed
    PSMs after RP is independent of the zonal location of the
    index tumour. However, tumour zonal origin may have an
    indirect influence on PSA relapse, as TZ tumours tend to be of
    large volume and more likely involve the bladder neck margin,
    both risk factors for BCR. Bladder neck margin involvement is
    associated with higher rates of BCR than other sites of PSMs.
    The preoperative identification of TZ tumours might aid
    surgical planning with appropriate alteration of RP technique
    to incorporate wider surgical margins at the bladder neck.
    Adjuvant radiotherapy appears to be associated with adverse
    outcome for TZ tumours, a novel finding which warrants
    further investigation.
    Too late now for proper surgical planning. But perhaps it will be helpful to someone else. Their finding about poorer outcomes for ART is especially interesting and is going to be a top question when we see the RO.

    And an update:

    Recovery is going as well as can be expected for someone in their early 40s who had a top Cleveland Clinic surgeon do the prostatectomy. At 3 weeks, minimal leakage - a light pad a day is adequate, erections happen without physical stimulation, just low dose daily cialis to encourage blood flow. It’s going to be a while before he can work again, but I’m hoping just another couple weeks and he can handle preschool drop off.

    In terms of follow up we’re unwilling to wait until the end of October to get a PSA test and discuss the pathology report with the surgeon. At literally every step of this process doctors have constantly reassured us that things will be fine and had zero sense of urgency, and at every turn the news has been bad. If ART is needed, studies would indicate the sooner the better, why wait until the 4 month mark to even schedule with an RO?

    So, the current plan is to order a uPSA test from Labcorp at the 6 week mark. We should have the Decipher report back sometime around then as well. We are taking the uPSA number, the decipher report, and the pathology report to a local radiation oncologist with an outstanding reputation for his opinion.

    If, heaven forbid, the PSA comes back at .2 or higher (which given our luck wouldn’t shock me), I have IDd two PSMA-PET studies within reasonable driving distance to try and get him into as quickly as possible.

    Question for those that have done a PSMA-PET - how long did it take to get it done from your first phone call to the trial coordinator?
    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. #2
    Thank you for this.
    The poor outcomes for RT is concerning... But I am not going to weigh too heavily on it right now. Were those with the poor outcome of higher gleason score?

  3. #3
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    It's not super clear, but it would make sense that anyone with higher gleason grades was selected to ART by their doctors. (Retrospective study after all) It's also very small numbers, and therefore many differences didn't reach statistical significance.

    TZ tumours in the adjuvant and
    non-adjuvant groups shared similar clinicopathological
    characteristics with similar preoperative PSA levels (mean 10
    vs 7.55 ng/mL, P = 0.91, proportion of Gleason score ≥4 + 3
    = 7 (48% vs 33%, P = 0.589) and tumour volume (mean 7.96
    vs 8.16 mL, P = 0.91, although the adjuvant-therapy group
    were more likely to have a higher stage tumour (≥T3a 76.2%
    vs 30%, P < 0.001).
    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

  4. #4
    TZ tumours in the adjuvant and non-adjuvant groups shared similar clinicopathological characteristics with similar preoperative PSA levels (mean 10 vs 7.55 ng/mL, P = 0.91, proportion of Gleason score ≥4 + 3 = 7 (48% vs 33%, P = 0.589) and tumour volume (mean 7.96 vs 8.16 mL, P = 0.91, although the adjuvant-therapy group were more likely to have a higher stage tumour (≥T3a 76.2% vs 30%, P < 0.001).
    "Bladder neck margin involvement is associated with higher rates of BCR than other sites of margin positivity. "
    At first glance it looks like this retrospective study was apples to semi-apples. The adjuvant groups had a higher tumor stage on average and did less well than the non-adjuvant groups. OK, but 70% ≥T3a vs 30% for each group, respectively?? That's quite a difference.

    T3b, for example, means SVI+, so mPCa may have been in play from that long before the ART for those men.

    Also your .07 very low risk Decipher score could mean a world of difference!

    Djin

  5. #5
    Quote Originally Posted by DjinTonic View Post
    At first glance it looks like this retrospective study was apples to semi-apples. The adjuvant groups had a higher tumor stage on average and did less well than the non-adjuvant groups. OK, but 70% ≥T3a vs 30% for each group, respectively?? That's quite a difference.

    T3b, for example, means SVI+, so mPCa may have been in play from that long before the ART for those men.

    Also your .07 very low risk Decipher score could mean a world of difference!

    Djin
    This study is pretty depressing actually... So if you are T3a TZ tumor with positive BN margin (my husband) you are pretty much doomed for BCR and then if you receive RT it doesn't cure it?
    What about a localized G6?
    And what dose of radiation did they use in this study? There is some info missing here...
    Wife Posting, Husband 44 years old at DX 1/19
    LUTS for several years
    7/18 PSA 2.3 Free 17%
    1/19 PSA 1.9 Free 11%
    1/19 MRI- Pirads 4
    2/19 Targeted Biopsy 1/13 3+3 <15% core (targeted)
    3/19 Oncotype DX score 12 (very Low risk)
    AS recommended by multiple doctors- Opted to be proactive

    4/19 nerve sparing RALP at UCLA
    Great recovery, NO ED, No meds, Mostly dry, no pads after 1st month

    Final Path! T3a grade 1 G6
    Huge 3.8cm Tumor in anterior transition zone of prostate
    3mm positive margin at Bladder neck, microscopic invasion of Bladder neck
    PNI+

    07/19 <.01 PSA

  6. #6
    Quote Originally Posted by Caligirl77 View Post
    This study is pretty depressing actually... So if you are T3a TZ tumor with positive BN margin (my husband) you are pretty much doomed for BCR and then if you receive RT it doesn't cure it?
    What about a localized G6?
    And what dose of radiation did they use in this study? There is some info missing here...
    However your husband is G6 (with a good genomics results to boot). First, only a portion of men with BCR go on to clinically recurrent disease. Secondly, many of the men who advanced had much more serious disease. And the study looked at a relatively short follow-up period. It was a retrospective, not prospective, study: that means it lumped together men with variable treatments as long as they fit into the two broad study groups. If one gets ART it's because your post-op status requires more treatment regardless of PSA. This is different than those who can wait and monitor their PSA and have salvage treatment only if needed, as indicated by a detectable and rising PSA.

    A G6 that does need "clean-up" RT because of its location, IMO shouldn't cause much greater worry than it did before surgery.

    Djin
    Last edited by DjinTonic; 08-08-2019 at 05:36 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

  7. #7
    Experienced User
    Join Date
    Nov 2017
    Posts
    84
    To answer your question about pet scan scheduling, I had the test approx. two weeks after order. However, my nurse navigator told me at my first call that it was a lengthy approval process with many carriers.

  8. #8
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    Join Date
    Apr 2019
    Posts
    68
    Quote Originally Posted by enock View Post
    To answer your question about pet scan scheduling, I had the test approx. two weeks after order. However, my nurse navigator told me at my first call that it was a lengthy approval process with many carriers.
    Thanks for that response, though I'm now learning that PSMA doesn't do well with bladder adjacent cancer, and since that's where the positive margin was PSMA may not work. Fingers crossed his PSA comes back low enough we don't need to seek a sophisticated scan.
    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

  9. #9
    Quote Originally Posted by AceVA View Post
    Thanks for that response, though I'm now learning that PSMA doesn't do well with bladder adjacent cancer, and since that's where the positive margin was PSMA may not work. Fingers crossed his PSA comes back low enough we don't need to seek a sophisticated scan.
    The 68Ga-based antibody is eliminated in the urine and accumulates in the bladder, which also lights up, making it hard to discern adjacent lesions. 18F-fluciclovine scans don't have that problem and their overall performance is almost as good as the Ga-based.

    Djin
    Last edited by DjinTonic; 08-09-2019 at 02:35 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

  10. #10
    Experienced User
    Join Date
    Apr 2019
    Posts
    68
    Quote Originally Posted by Caligirl77 View Post
    This study is pretty depressing actually... So if you are T3a TZ tumor with positive BN margin (my husband) you are pretty much doomed for BCR and then if you receive RT it doesn't cure it?
    What about a localized G6?
    And what dose of radiation did they use in this study? There is some info missing here...
    I agree this study raises a lot of questions, especially about the poorer outcomes from RT- they even say it's a novel finding, and it's a small N. Not going to read too much into that part until I've had a nice long talk with the RO.

    If the G6 was organ confined - no BNI, then it wouldn't be pT3 staged and the stats are great. Unfortunately, the upstaging caused by the BNI comes with depressing stats. Pre-2009, even all G6 with BNI would have been pT4! I've been going through every study from the re-staging decision in '09 and working my way forward in time looking at incidence of BNI, incidence of isolated BNI, and the likelihood of biochemical recurrence. I can't seem to get a screenshot of my spreadsheet so far to attach - but the incidence of BNI with an isolated positive margin at the bladder neck, without SVI or positive nodes is really, really low - .46%-2.5% of all prostatectomies in the 8 studies I've gotten through so far. Biochemical recurrence, regardless of Gleason score, is in the 30-60% range.
    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

 

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