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Thread: Update on my RALP and Pathology Report

  1. #1
    Regular User
    Join Date
    Aug 2019
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    Update on my RALP and Pathology Report

    It's been a little over two weeks since I had my DaVinci RALP procedure done. For those of you thinking the day will never come, it does, and it goes by in a flash. Here are a few observations of my own personal experience:

    RALP and subsequent days

    *First impression in hospital: Nurse #1: Male...Nurse#2: Male...I was like you got to be kidding!! They were great though as was everyone else.

    *To help pass the first amount of gas, drinking water and eating some crackers definitely got the ball rolling for me.

    *I didn't really feel any pain while in the hospital. Tight stomach yes, but no pain.

    *Once at home the first day, I walked around my house for an hour straight. I also walked in 3-45 min segments/day over the course of the week (adding some music makes it a little more bearable. I think it definitely helped to reduce the gas in my stomach but I would advise to wear sneakers. I walked (more like shuffling my feet the first few days) in my house on hardwood floors in just socks and then slippers. I paid the price later when I got tendonitis in my calves.

    *My dog and cat looked at me very strangely when I was walking around with the catheter bag...ESPECIALLY the cat!

    *The catheter wasn't really a problem at all. I preferred the big bag and just cut out a little side of my sweats so the tube would fit out. I strapped that tube to my thigh so it wouldn't move and that helps a lot.

    *My wife is truly an angel. Helped me with so much. Bought her some very nice flowers a few days ago. Priceless

    *The only time I experienced any pain with the catheter was when I placed my laptop on my lap and it must have pinched the tubes or something. I started to get this pain like I had to pee really bad and then got up and I saw the bubbles and stuff start to move through the tubes again. What a relief!

    *Catheter removal was no big deal. I had a small pad in for a week but not any longer and haven't experienced any incontinence or leakage at all.

    *I didn't experience any bladder spasms in the hospital but five days after catheter was removed I had quick, sharp pains down there somewhere. Doc said those were spasms and are common. I probably should have kept my water intake up but I backed it down once it came out.

    *ED: Seemed like it was pretty dead down there but I know he'd been through a lot. Started to perk up a few days ago but I didn't let it go to the max because I was afraid of the feeling when I ejaculate.Doc said it's ok so we'll see. I'll be started 5mg Cialis in a few days.

    POST RP Path Report

    I guess the optimist in me was thinking OK today I get the gold star from the teacher and we walk out feeling super! I know, a little delusional but as all of us know, that once we step on the field in this game, we never really leave it for life. Living in the moment and processing things as they come surely helps.

    *Gleason 3 + 4 = 7 (was 3 + 3 = 6 on biopsy)

    *Grade Group 2

    *Percentage of prostate involved by tumor: 6%

    *EPE, BNI, SVI, Lymph invasion, Margin positivity in area of EPE: all of these were not identified

    *Margin involved by invasive carcinoma: Limited (<3mm), Focality: Unifocal, Location: Left Mid Posterior----I wish I could know the Gleason score in this area?? Not reported. Has anyone had theirs reported separately in addition to the primary tumor?

    *PNI: Present

    *Pathological Staging: T2 N0 MX

    Overall, doc said things were good. She did note the +margin but didn't seem concerned and also PNI which she said is common. First PSA test in Feb.

    Has anyone done adjuvant radiation for Grade 2 and +Margin after RALP? In Walsh's book he mentions to strongly consider it. I'll be speaking w my Dr in a few weeks again. I always have additional questions after our initial meetings!

    All thoughts, etc are welcome. Thanks much.
    Age 52, No symptoms, healthy, GrF had PCa at age 78
    First PSA test ever 5/2019: 7.037 (referred to urologist)
    Normal DRE
    PSA 7/2019: 5.152, Free 8%
    PSA 8/2019: 4.652, Free 7%
    Biopsy 8/16/19
    Dx PCa 8/30/19
    16 cores taken/ 5 positive for PCa
    L Apex and L Mid: (G 3+3=6) involving 2 cores, 10% of ea / Grade Group 1
    L Lat Apex: (G 3+3=6) involving 20% of 1 core/ Grade Group 1
    L Lat Mid: (G 3+3=6) involving 60% of 1 core/ Grade Group 1
    L Medial Mid: (Gleason 3+3=6) involving 70% of 1 core/ Grade Group 1

    DaVinci RP 10/10/19 Nerve Sparing
    Post RALP Path:
    G 3 + 4 = 7 (was 3 + 3 = 6 on biopsy)
    Grade Group 2
    % of prostate involved by tumor: 6%
    EPE, BNI, SVI, Lymph invasion, Margin positivity in area of EPE: All of these were not identified
    Margin involved by invasive carcinoma: Limited (<3mm), Focality: Unifocal, Location: L Mid Posterior
    PNI: Present
    Pathological Staging: T2 N0 MX

  2. #2
    Hi FishnReps! It looks like you had a very soft landing on "The Good Side of RP!" Congrats! Glad to read that all is going so well.

    At this point, considering ART should not be on your list of concerns! Simply discuss all of the issues with your URO Surgeon at your next meeting. As a result of the (+) Margin, ask if you should monitor your PSA by an ultrasensitive Methodology (uSPA). This will allow identification of a rising PSA at the earliest time point.

    Meanwhile, keep up your walking routine with increasing frequency, pace and duration as able. Refrain from any heavy lifting or twisting motions until cleared by your URO Surgeon.

    Good luck! Keep us updated.

    MF
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free = 0.39ng/ml, % PSA Free = 13%)
    Referred to URO MD
    Jan '12: DRE = Positive: "Left induration"
    Jan '12: Biopsy = 6 of 12 Cores were Positive: 1 = G7 (3+4) and 5 = Gleason 6
    Referred to URO Surgeon
    March '12: Robotic RP: Left: PM + EPE. MD waited in surgery for preliminary Path Report then excised substantial left adjacent tissue(s) down to negative margins and placed 2 Ti clips for SR guidance, if needed in future.
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    3 month Post Op standard PSA = <0.1 ng/ml
    1st uPSA at 7 months Post Op = 0.018 ng/ml
    uPSA remains "stable" at 91 Months Post Op: Mean = 0.022 (22x uPSAs: Range 0.017 - 0.032) LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%)
    ED = present

  3. #3
    Well done, FishnReps!

    That's a very good pT2 post-op path report. I would point out the not only was the SM+ <3 mm, but it was focal, meaning occurring at a single point. This, of course, is better a multifocal finding, or a more serious extensive positive margin.

    I would point out that your low, 6% tumor involvement in the whole prostate is a good indication that the cancer was not overly aggressive. Your doc wields a wicked biopsy probe and monitor to have seen the suspicious areas and come up with 5 out of (probably) 8 positive biopsy cores on the Left side! (my uro got just 2 out of 16 positive cores for my 5% bilateral PCa involvement)

    Yes, PNI+ found at RP is common.

    I agree with Michael F -- I don't think there are many docs who would advise ART on the basis of your having a small SM+ as your only adverse feature! If your first post-RP PSA test is undetectable, it will confirm a successful primary treatment.

    Yes, some path reports do mention the G score at the positive margin. If, as I suspect, your PSA comes back looking good, I think you should accept the victory (I agree with Michael that a 2- or 3-digit PSA test will let you monitor your PSA more precisely). However, if you are concerned, you can speak to your doc about having the Decipher test run on tissue removed at the RP. But this can definitely wait until you show signs of a rising PSA (if you ever do).

    Djin
    Last edited by DjinTonic; 10-25-2019 at 11:42 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(5L, 11R): 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 retest)
    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. #4
    Regular User
    Join Date
    Aug 2019
    Posts
    16
    Thanks Michael & Djin!

    Yep, I'm schedule for my first ultraPSA in Feb and it'll be every 3 months for the first year.

    Time to chill for a bit. I left work early today and went fishing. Nice to think about something else for a change.
    Age 52, No symptoms, healthy, GrF had PCa at age 78
    First PSA test ever 5/2019: 7.037 (referred to urologist)
    Normal DRE
    PSA 7/2019: 5.152, Free 8%
    PSA 8/2019: 4.652, Free 7%
    Biopsy 8/16/19
    Dx PCa 8/30/19
    16 cores taken/ 5 positive for PCa
    L Apex and L Mid: (G 3+3=6) involving 2 cores, 10% of ea / Grade Group 1
    L Lat Apex: (G 3+3=6) involving 20% of 1 core/ Grade Group 1
    L Lat Mid: (G 3+3=6) involving 60% of 1 core/ Grade Group 1
    L Medial Mid: (Gleason 3+3=6) involving 70% of 1 core/ Grade Group 1

    DaVinci RP 10/10/19 Nerve Sparing
    Post RALP Path:
    G 3 + 4 = 7 (was 3 + 3 = 6 on biopsy)
    Grade Group 2
    % of prostate involved by tumor: 6%
    EPE, BNI, SVI, Lymph invasion, Margin positivity in area of EPE: All of these were not identified
    Margin involved by invasive carcinoma: Limited (<3mm), Focality: Unifocal, Location: L Mid Posterior
    PNI: Present
    Pathological Staging: T2 N0 MX

  5. #5
    Your PSA in 60-90 days will give you the first indication. Anything <.03 is good.
    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 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (<1 month)
    4/25/19 <.03. (2 months)
    5/25/19 <.02. (3 months)
    9/10/2019. <.02. (6 months)
    11/27/2019. <.02. T<3. (9 months)

    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. #6
    Your pathology sounds a lot like mine did. I was undetectable for a year, then it became detectable. 18 months after surgery I went through salvage radiation. My RO told me that if I had had the surgery "now" instead of a year prior, adjuctive radiation would have been recommended because of the + margin. The standard treatment recommendation had changed.

    This doesn't mean this will be your case and hopefully it isn't. Hopefully you will be undetectable and remain so.
    Last edited by DavefromMD; 10-26-2019 at 12:59 AM.
    There is no right or wrong decision for treatment. Make the decision you are comfortable with and can live with and not second guess if all does not go optimally.

    6/2016 PSA 5.1, negative DRE
    6/2016 Urologist PSA 6.0, %free = <10% chance cancer, negative DRE
    12/2016 PSA 7.7, %free = 50% chance cancer, negative DRE
    2/2017 biopsy Hopkins 5/12, 4 3+3, 1 3+4 (5% 4), perineural invasion
    5/17/2017 Open RP by Dr Alan Partin - Hopkins
    5/2017 Pathology 3+4, T2x, +margin (6mm, 3+3), organ contained except unevaluable at +margin, moderate tumor extent
    seminal vesicles, lymph nodes all neg
    Age: 62 @ surgery
    8/2017 PSA < .1
    11/2017 PSA <.1
    5/2018 uPSA .06, standard .1
    8/2018 uPSA .07, standard .1
    11/2018 uPSA .10, standard .1
    12/29/2018 6 month Lupron shot
    1/22/2019 start SRT, 39 treatments, 5 days per week
    3/15/19 ended SRT with no significant side effects
    6/2019 PSA <.02
    11/2019 PSA < .014 (different lab)

  7. #7
    Quote Originally Posted by DavefromMD View Post
    Your pathology sounds a lot like mine did. I was undetectable for a year, then it became detectable. 18 months after surgery I went through salvage radiation. My RO told me that if I had had the surgery "now" instead of a year prior, adjuctive radiation would have been recommended because of the + margin. The standard treatment recommendation had changed.

    This doesn't mean this will be your case and hopefully it isn't. Hopefully you will be undetectable and remain so.
    I believe if you looked up the NCCN recommendation for you pathology wait and see or ART may have both been listed.
    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 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (<1 month)
    4/25/19 <.03. (2 months)
    5/25/19 <.02. (3 months)
    9/10/2019. <.02. (6 months)
    11/27/2019. <.02. T<3. (9 months)

    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)

  8. #8
    Senior User
    Join Date
    May 2017
    Posts
    222
    I had very similar post-surgery pathology as you. Though my biopsy showed 3+4 = 7 and thankfully it stayed that after surgery. I had a very small positive margin of 1mm and Grade group 2. My PSA was undetectable until about a year and a half after surgery then it began to creep up. I didn't wait for it to get very high before starting salvage radiation. I believe it reached about .06 before I started. I finished SRT ABOUT 4 MONTHS AGO AND MY RO wants me to wait until 6 months post SRT to get my PSA checked. I am a little nervous waiting that long but I'm doing it. Hopefully it will be undetectable. The grade at my positive margin was recorded as pattern 3 so I was happy to see that. So in answer to your question, it is potentially possible you could BCR with your pathology.

    Tim
    Age at diagnosis: 57
    8/15/14 PSA 2.9
    3/01/17 PSA 5.9
    5/1/17 Biopsy Results
    6 cores positive out of 12
    1. G 6 - 45%, 2. G7 (3+4) - 70%, 3. G6 - <5%, 4. G7 (3+4) - 40% Perineural Invasion Identified
    5. G6 - 15%, 6. G6 - 15%
    CT and bone scan negative
    Biopsy second opinion by the Cleveland Clinic: Still G3+4 (% of pattern 4 in each of two cores = 5% of tumor)
    Pre Surgery PSA = 6.11, Free PSA = 13%
    Davinci performed August 1, 2017 at Cleveland Clinic
    Catheter out August 9, 2017
    Pathology: Pathologic Stage - pT2: Organ confined, Gleason Score 3+4=7: Grade Group 2.
    % of pattern 4: 1-10%, % of pattern 3: 91-100%
    SV -, BN -, LN -
    Margin of resection is focally positive for tumor, Length of positive margin: 1mm
    Gleason pattern at positive margin: Pattern 3.
    Post-Op PSA History: 9/14/17 <.03, 11/10/17 <.03, 5/10/18 <.03, 7/19/18 <.03, 9/15/18 <.03, 11/14/18 .03, 02/18/19 .05, 3/12/19 .05, 4/22/19 .06
    SRT begin 5/7/19, 70.2 gy total in 35 fractions.

 

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