Help interpretating Path report

bcdoo · Regular Joined: 09 Feb 2008 Posts: 18 Location: Texas

I had RP 1/22 and the path report:

Gleason 4+4 (originally 3+3,1 of 5 cores in less than 5% of tissue)
Involves both sides of the apical region
Tumor volume of 1.5x1.2x0.8 cm.
Perineural invasion was present
Tumor extended focually to inked margin over 2mm length
Not evidence of extraprostatic extension
No seminal vesicle involvement
The proximal and idstal urethra, left and right apical and left and right bladder base margins were free of tumor
T3, R1, NX, M0 prostatic cancer
Father died of metastatic prostate cancer at 73
PSA test in 2 months.

Any thoughts on where my levels of concern, actions and expectations should be?

Thanks

BDOO
Last PSA: 4.73
Age: 57

Replicant · Moderator Joined: 01 Nov 2006 Posts: 206

Well, the Gleason 8 puts the cancer in the aggressive camp, no doubt about it.

Perineural invasion -- it DOES place you technically into stage T3, but there is some debate among researchers as to whether or not it should. But it's not as threatening as having seminal vesicle involvement--which, thankfully, you seem to be clear of.

Nx means the lymph nodes were not dissected, so there is no information there.

Good news on lack of extracapsular extension.

You have positive margins (tumor extended to inked edge).

My layperson's take on this is that you will need to watch your PSA very closely. You might ask about adjuvant radiation--that is, radiating the area very soon, without waiting to see if PSA goes up. At any rate, you will want to talk with your doctors about what to do if PSA does not go down, or if it rises. Radiation combined with hormone treatment might be an option in that case.

You could obtain a copy of the Stephenson article I mentioned in the posts below to Hawk. It could help you chart out your path in the event your PSA rises.

The Gleason 8 is worrisome. However, you have positive margins and if you have a PSA recurrence, the margins provide a reasonable explanation for the PSA--cancerous tissue left behind, still in the prostate bed, and treatable with radiation. No guarantees, of course, but a logical possibility. Hey, it happened to me..
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

chas036

With Gleasson of 8 and positive margins, I would make an appointment very soon with an ocologist and discuss radition. Positive marins means that it has escaped out the prostate and with an Gleason of 8,,that is not something you should take a wait and see attitude. With aggressive traetment, you can live a long and cancer free life, but you have to find a doc who knows what he is doing. Take a look at this,,,it should give you some motivation.

http://www.ustoowichita.org/cmaackprostatecancerstats.cfm
_________________
Biospy 4/2007 - 2/12 <%5 Cancer Gleason 6
RP 9/25/2007 Uni Rochester, NY
Gleason 6, Negative Margins

bcdoo · Regular Joined: 09 Feb 2008 Posts: 18 Location: Texas

Thanks for the replies. I must confess, I am totally overwhelmed with the information from so many sources. I know I am still recovering from the surgery and the big life changes and am fortunate that I have had virtually no leaking at all. But am concerned about waiting to see what post surgery PSA levels are like....guess it is my type A personality that likes to be in control....I am working with a Dr. in Dallas and the urosurgeon at the MAYO Clinic in PHX who did the RP. They both agree on waiting until we see where the PSA is going. Guess any residual PCA can be tracked to the positive margin noted?

Replicant, I thought I was young for this diagnosis, you are in your forties? Your path appears similar to mine...what was your experience with salvage radiation?

Really appreciate the comments.

BDOO

Replicant · Moderator Joined: 01 Nov 2006 Posts: 206

BDOO,

First--any residual PCa can't be definitively tracked to the remaining stuff from the margin. It's a logical explanation, but not the only one. If your PSA rises, it could be from the prostate bed, or distant disease, or both. If that time comes, you'll have to evaluate the probabilities and make a decision. No guarantees!

Anyway, my story is detailed in my blog, but in brief: I had surgery in the Phoenix area, but at a local hospital. (My insurance does not cover Mayo). Robot-assisted. My first post surgical PSA was less than 0.1, but it was 0.2 the next time around and kept going. I started salvage radiation (IMRT) at the same hospital, in January 07 and finished in March. 39 treatments.

IMRT is as easy as falling off a log, as far as undergoing the treatments. There is some kind of alignment done each time. For me, it was three tiny tattoos, which the techs lined up with laser crosshairs. In order for that to work, some slight disrobing (dropping the pants a little, pulling up the shirt) was needed. In other hospitals--including Loma Linda--they'll make a partial cast of your body for you to lie in so you're in the exact position every time.

I'd just lay there for about 12-15 minutes while the machine whirred and buzzed, moving into different positions.

There is no sensation. You're just getting x-rays, albeit quite a few of them.

I felt like I was a VIP. Radiation patients get to park right by the door, and use a semi-secret entrance, and go into a nice private waiting room for a few minutes. Then the therapists would come get me, and we'd all chat about what we were doing over the weekend, etc., as they got me lined up.

Over time the radiation builds up to a total dose. As that happens, side effects can manifest themselves. After my 10th session, I started noticing that my bowels were pretty active. That gradually got more pronounced, and I slowed things down with Imodium. Then right at the end of treatment, I started having pain with bowel movements. I got a prescription for Proctofoam which took care of the pain. Over the following year, that side effect has gotten much better. No more pain, no more diarrhea, but I do have at least 2 bowel movements each day (hey, some people should be so lucky!)

(That's just my anecdote. Other people have different experiences with side effects.)

The radiation knocked my PSA down.

Before I met with the radiation oncologist, I had been through the numbers on the Stephenson nomogram and things didn't look favorable. But I had an incorrect assumption--I had thought my margins were negative. When I found they were positive, that changed the probability from being against me to being slightly in my favor.

I also met with a medical oncologist, who told me that hopefully I would never need his services, but to come back to him if radiation failed to control my PSA.

Throughout salvage, it was hard for me to believe that these invisible rays were attacking my cancer. It seemed almost like magic--invisible somethings attacking something that was practically invisible itself. Would it work? Was I REALLY lying in the same exact position every day? What if the therapists were having a bad day? Smile

Was I doing all this for nothing? Only time would tell.

And only time WILL tell, in the long run. My reading of things is that I have an excellent chance now of being progression free for the next few years, but after that it gets a little dicier. Out to 10 years, my likelihood of success drops down to about 35%. I need to be free of PCa for 3 or 4 decades, not just 1 or 2 decades like the average patient who is twenty years older. What's good enough for the 70 year old probably isn't good enough for me. I have too long to go to outlive prostate cancer. One of us is going to win in the end--either I get rid of it, or it will most likely kill me before something more boring does.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

bcdoo · Regular Joined: 09 Feb 2008 Posts: 18 Location: Texas

Replicant,

Thanks for the info and all the details. Mayo has done a good job and I trust that we will watch closely. Seems like family DNA, history of mortality around PCA and current state are not too good, but, just working to make sure this thing is last in line to kill me. I am a triathlete and century bike rider who is losing his mind right now because I am getting soft. Guess a little ice cream won't kill me either Smile

.

Not sure I really understand positive and negative margins, would you be kind enough to explain?

Thanks again so much for the patience and information.

BDOO

Replicant · Moderator Joined: 01 Nov 2006 Posts: 206

A little ice cream now and then is a comfort to the soul, no doubt! Today I'm eating those Healthy Choice vanilla ice cream sandwiches laced with caramel..

Anyway, as to margins. Here's how Walsh puts it:

Positive margin:

"the presence of cancer cells at the cut edge of the removed prostate specimen...a positive margin can mean one of two things: It can mean that the tumor extends outside the prostate, to a point where the surgeon can't remove it all. But it often means that the boundaries of the prostate are indistinct, and the surgeon cut extremely closely along the edges of the prostate" (p. 277)

On page 362, he talks about how prostate cancer is multifocal, starting up in many places in the prostate simultaneously. "This is why surgeons must work very hard to remove the entire prostate and avoid positive margins.."

on 365, he explains that after surgery, the prostate goes to the pathologist, "who immediately coats the outside of the entire specimen..with India ink". The prostate is then put in fixative, then sectioned, stained, and looked at microscopically. In a positive margin case, the pathologist "can see cancer cells at the edge of the India ink, and this suggests there may be cancer beyond the outermost edge"

However, Walsh says that sometimes a positive margin does not necessarily mean there is cancer on the other side. One way this could happen is if the surgeon actually cut across the last few tumor cells. Or the surgical procedure itself finishes off the remaining cells by cutting off the blood supply. Lastly, it's possible that the positive margin report comes because the removed prostate gets handled so much by the surgeon, the nurse, the pathologist, etc. that where there was a margin originally, there isn't any more because the thin layer "buffer" cells constituting the margin got rubbed off.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

bcdoo · Regular Joined: 09 Feb 2008 Posts: 18 Location: Texas

Replicant,

Thanks for the comments and all the best for a long life!

BDOO

bcdoo · Regular Joined: 09 Feb 2008 Posts: 18 Location: Texas

What are your thoughts, given the Gleason 8, T3a and positive margins to getting a bone scan and/or MRI?

BDOO

Replicant · Moderator Joined: 01 Nov 2006 Posts: 206

No, not unless and until recommended by an oncologist.

PSA would almost certainly be your first warning sign. For all the controversy over PSA, it is extremely valuable in the post-surgical setting.

Years before anything would show on a scan, your PSA would become elevated and start tracking upward.

If you need adjuvant or salvage radiation, your doctors may want another bone scan, not because they expect to see anything, but as a baseline. Then again, the one from before your prostatectomy might suffice.

In my case, my radiation oncologist wasn't very interested in scans besides the 3D CT planning scan. But I consulted a medical oncologist as well. He ordered a bone scan, which was clean.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

brainman

bdoo, I know I have never replied to you but I have read all of your posts. I totally agree with Replicant; until your PSA starts to rise, there really is no point to have any scans. The positive margin results are worrisome. What adjuvant (post surgery) treatments are you receiving?
_________________
Jim
Site Administrator and long-term cancer survivor
1992 Astrocytoma grade 2, left motor strip
2005 Recurrence this time said to be an Oligodendoglioma grade 3, same location.
My Story Part 1: http://cancerforums.net/viewtopic.php?p=7350
My Story Part 2: http://cancerforums.net/viewtopic.php?t=8029
Blog http://jimhawkinsport.blogspot.com/

Replicant · Moderator Joined: 01 Nov 2006 Posts: 206

BCDOO, you might be interested in this article:
http://www.medicalnewstoday.com/articles/43871.php
Quoting from the article:
"Dr. Slawin also discussed that up to 50% of patients with a positive surgical margin at radical prostatectomy will never experience a clinical recurrence. As such, half of patients will be receiving treatment unnecessarily. If monitored, a rising PSA can prompt salvage radiotherapy and if given before the PSA rises to >1ng/ml, outcomes may be similar to the adjuvant setting."

Good luck!
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

bcdoo · Regular Joined: 09 Feb 2008 Posts: 18 Location: Texas

With the T3a and positive margin as well as family history of metastesis, would I simply get some peace of mind with a scan or MRI as a baseline?

Thoughts?

Thanks

BCDOO

Replicant · Moderator Joined: 01 Nov 2006 Posts: 206

I think that's a question only you can answer for yourself.

Speaking for myself, if I were in the same situation (and I wasn't far off at one point), scans would not buy any peace of mind. They only help rule out metastasis. They cannot rule out cancer that is systemic but not to the point of showing metastases--and the average time before metastases show up after PSA recurrence is 8 years (see Walsh, p. 386).

PSA is the canary in the coal mine. It will start to rise way before scans show anything. It will rise when there is micrometastatic spread (spread that does not show on scans). A continued PSA below 0.1 is my only source of assurance that I'm not having a recurrence.

On page 381, Walsh says, under the heading "My PSA is Elevated: Should I get Radiation?":

"Could radiation therapy (this is called salvage radiation) eradicate any remaining prostate cancer cells? Or would it just cause new complications by needlessly treating an area already free of cancer? This is not an easy question to answer--in part because PSA is so very sensitive, and when so few cancer cells are present, they can't be seen by any of the usual imaging studies, such as MRI or CT."

The information cited as "Walsh" comes from "Dr. Patrick Walsh's Guide to Surviving Prostate Cancer" by Patrick C. Walsh, MD and Janet Farrar Worthington (New York: Warner Wellness, 2007). I highly recommend this book to all men.
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

brainman

Again, I agree with Replicant. If I had a history of Prostate cancer, an MRI or any other scan would not give me peace of mind. Prostate Cancer is different from Brain Cancer, for example, or even Breast Cancer. MRI or other scans tend to have a lot of false negative results when it comes to Prostate Cancer. But the decision is yours; if it will bring some peace of ming to you, it will not hurt you to have a scan done.
_________________
Jim
Site Administrator and long-term cancer survivor
1992 Astrocytoma grade 2, left motor strip
2005 Recurrence this time said to be an Oligodendoglioma grade 3, same location.
My Story Part 1: http://cancerforums.net/viewtopic.php?p=7350
My Story Part 2: http://cancerforums.net/viewtopic.php?t=8029
Blog http://jimhawkinsport.blogspot.com/

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