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  • #1

    Post RALP path report

    reposting here, inadvertently posted on members only.

    Just got back the path report. Pt3b. I doubt my urologist even saw it yet. Good, on EPE or lymph involvement. Not so good, SVI, Margins and bladder neck involved. What are the main questions for Urologist? I don't have a MO or RO yet. I will start the search. Does this indicate sooner adjuvant therapies than later salvage?

    A: Fat of prostate:
    Adipose tissue negative for carcinoma.
    B: Prostate, prostatectomy (39 g):
    ADENOCARCINOMA, Gleason score 4 + 3 = 7 (Grade Group 3), with bladder
    neck invasion and bilateral seminal vesicle involvement; see staging
    summary below.
    Tumor
    Histologic Type: Acinar adenocarcinoma
    Histologic Grade
    Grade: Grade group 3 (Gleason Score 4 + 3 = 7)
    Minor Tertiary Pattern 5 (less than 5%): Not applicable
    Percentage of Pattern 4: 61 - 70%
    Intraductal Carcinoma (IDC): Not identified
    Cribriform Glands: Present
    Treatment Effect: No known presurgical therapy
    Tumor Quantitation
    Estimated Percentage of Prostate Involved by Tumor: 11 - 20%
    Extraprostatic Extension (EPE): Not identified
    Urinary Bladder Neck Invasion: Present
    Seminal Vesicle Invasion: Present, bilateral
    Lymphovascular Invasion: Not Identified
    Perineural Invasion: Present
    Margins
    Margin Status: Invasive carcinoma present at margin
    Margin(s) Involved by Invasive Carcinoma: Right bladder neck; Left
    bladder neck; Posterior
    Regional Lymph Nodes
    Regional Lymph Node Status: All regional lymph nodes negative for
    tumor
    Pathologic Stage Classification (pTNM, AJCC 8th Edition)
    Primary Tumor (pT): pT3b
    2/17/22 PSA of 19.2 in blood lab from general physical. Referred to Urologist.
    3/10/22 Urology 1st visit. DRE (unremarkable) New PSA lab 18.8
    4//14/22 12 core biopsy.
    Left base - Gleason 4+3, Gleason pattern 4/60%.. carcinoma 2 of 2 cores 5-10% of tissue..
    Left mid Gleason 4+3 , Gleason pattern 4/90%..Cribiform 4 present, carcinoma 2 of 2 cores, 10% of tissue
    Left Apex Gleason 4+4, Gleason pattern 4/100%, Cribriform 4 present, carcinoma present in 2 of 2 cores, 5-10% of tissue. Perineural Invasion
    4/22/22 Bone scan (negative for MET) CT with contrast (also negative)
    5/12/22 EKG (ECG) UA and blood labs prior to Da Vinci LRP.
    5/30/22 Buy diapers. LOL
    6/2/22 scheduled procedure
    Let the journey begin
    Tags: None
  • #2
    Hi Michael,

    As you can see, there were a number of findings of adverse pathology in your report: seminal vesicle invasion, multiple positive margins, bladder neck invasion, and cribriform glands. The lymph nodes removed were all negative; however, I don't see the number removed. Did the report omit it or did you?).

    (IMO the estimate of your tumor burden (11 - 20%), the percentage of your prostate the cancer occupied is rather broad. It is usually a single number or sometimes a range but narrower). That your final Gleason score was a 7 and not higher is good, but it was a 4+3 rather than a less serious 3+4.

    Your first post-op PSA may be an important factor in deciding whether you'll be advised to have adjuvant therapy after a healing period or to wait and observe your future PSA trend and plan on salvage therapy if necessary. If you have "persistent PSA" (0.1 or higher), adjuvant therapy will very likely be advised.

    I strongly suggest you discuss having a Decipher Prostate test done on your removed prostate tissue to estimate the risk of metastasis (low, average, or high) of your particular cancer. This, too, could factor into a decision about if and when to have further treatment, and, perhaps, what PSA level would trigger such treatment. If your first PSA is below 0.1, I suggest you monitor it going forward with Labcorp's 3-digit, ultrasensitive PSA test, if possible. It will give you both an accurate measure of your actual value and will afford the maximum lead time to plan any treatment if your PSA should begin to rise.

    After your visit with your doc, you may want to have a consult at a prostate center of excellence. These institutions usually have an interdisciplinary team of experts review cases. They are up on the latest research, and have a large patient base, which gives them first-hand experience with treatment outcomes.

    Please keep us informed about what you learn and decide. Good luck on your post-op PSA values!

    All the best,

    Djin
    Last edited by DjinTonic; 06-08-2022, 08:07 PM.
    69 yr at diagnosis, BPH x 20 yr, 9 (!) neg. biopsies, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on right + 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
    Nodule neg. for PCa
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma
    5% of prostate (4.5 x 5 x 4 cm, 64 g) involved
    Dry; ED OK with sildenafil
    11-10-17 Decipher score: 0.37, Low Risk:
    5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%    		 9-16-17 (5 wk) PSA <0.1
    (3 m ) 0.010
    (6 m ) 0.009
    (9 m ) 0.007 (nadir)
    (1 yr.) 0.018 (?)
    (13 m) 0.013 (retest)
    (15 m) 0.012
    (18 m) 0.015
    (21 m) 0.015
    (2 yr. ) 0.016
    (28 m) 0.015
    (34 m) <0.014
    (40 m) 0.037 (?)
    (43 m) 0.020
    (46 m) 0.018
    (52 m) 0.023
    (5 yr) 0.038
    (63 m) 0.036
    (66 m) 0.049
    (69 m) 0.054

    Comment

    • #3
      Originally posted by Michael B from Washington View Post
      reposting here, inadvertently posted on members only.
      No problem, I took care of that.

      Does this indicate sooner adjuvant therapies than later salvage?
      With pathology such as yours (ours) the patient is generally recommended to proceed with adjuvant radiation and most likely ADT as soon as continence is regained, around 6-9 months, due to adverse pathology. Your high percentage of grade 4 (plus tert 5), extensive invasive invasion of surrounding tissues and double digit pre-op PSA puts you in the very high risk category.

      The surgeon who did my RP used the standard PSA post-op and told me that it was "undetectable" at <0.1, but recommended that I have adjuvant RT in about six months.

      Fortunately all this occurred just as my wife and I were in the process of relocating and my new Uro did frequent monthly ultra sensitive PSA's and started me in physical therapy with a Kegel coach. I found a genitourinary radiation oncologist near my new home (ten minute drive) and got the ball rolling. Unfortunately, continence never improved as my PSA crept up from <.01 to .03 and my new RO told me that there is usually little improvement in continence after nine months. So it was at that point that I had to decide on getting an artificial urinary sphincter (AUS) in order to proceed with RT.

      My approach was to throw everything at it rather than risking a "wait and see" attitude, as I had read that basically we only get once opportunity to get it right the first time. After a few SNAFU's I finally started ART one year post-op, and so far (fingers crossed) have remained truly undetectable or "no evidence of disease" for over five years. At that time there were no genetic tests that I was aware of, and have still never had one. But my grandfather died from metastatic PCa and that's evidence enough for me.

      My recommendation would be that you begin interviewing radiologists as soon as you are able and be prepared for a marathon. Note that several guys have mentioned that they were continent when they started RT but lost it during their treatments. Good luck to you. I hope your path forward goes well.
      Late 2012: PSA 4, age 62 all DRE's 'normal'
      Early 2014: PSA 9.5, TRUS biopsy (false) negative
      2015: PSA's 12 & 20, lots of Cipro ... Mar '16: PSA 25, changed Urologist

      Jun'16: MRI fusion biopsy, rt base, 2ea 15-40-100% G8(4+4)
      Aug'16:DVRP, "broad cut" 11 LN-, neg margins, gland 53g, 25% involved
      multifocal EPE, PNI, BNI, bilateral SVI, pT3b N0      		 Dec 2016: Mrs: Dx stage 4 NHL/DLBCL, Primary Bone Lymphoma
      spinal RT boost+6X R-CHOP21+6X IT MTX via LP.
      Remission ended 2020, Follicular NHL. Currently active surveilance.

      Mar 2020: older adult son, T-cell acute lymphoblastic leukemia (TALL)
      Hyper-CVAD + pegaspargase, RBC transfusions in NYC amid COVID-19
      Bone marrow transplant Oct 2020, currently in Remission
      Jan'17: began Lupron ADT, uPSA's ~.03
      May'17: AMS800 implanted, revised 6/17
      Aug'17: 39 tx (70 Gy) RapidArc IGIMRT
      Jan 2018-July 2022: PSA's <0.008, T ~ 50
      Apr'18: Dx radiation colitis, Oct'18: Tx sclerosing mesenteritis      		 June 2020: younger adult son, small bowel resection
      adenocarcinoma of lower ileum (SBA) w/+lymph node, stage T3a-N1
      Adjuvant chemo: 12x FOLFOX, currently in Remission

      "Everyone you meet is fighting a battle you cannot see"

      Comment

      • #4
        @RobLee, there was no finding of tertiary pattern 5 in Michael's path report. This is evidently a standard form that the pathologist fills out. The line in the report is:

        'Minor Tertiary Pattern 5 (less than 5%): Not applicable"

        In these reports you see the name of the adverse finding followed by "Not present", "Not applicable", or "Not identified" (The "less than 5%" is just an explanation of what is meant by a "tertiary" pattern. The advantage of this type of form is that the patient knows that the adverse finding wasn't found but erroneously left off the report. It's a reminder to the pathologist to cover everything, as well,

        SOC is moving toward early and very early SRT rather than adjuvant. This avoids overtreating men whose PSA won't rise. Also, recent studies are showing that early SRT may be just as effective as adjuvant. I think that--at least for now-- adjuvant will be advised for those with persistent PSA and men with G8 and up with significant adverse pathology.

        It's my hunch much will depend on the extent of the bladder neck invasion, the actual values of the post-op PSA, and, perhaps, the results of a Decipher test. But IF Michael's PSA is low, with his G7 final grade, his docs may advise waiting to see if adjuvant therapy can be avoided--we'll see. On the other hand, if a Decipher test comes back high risk for mets, adjuvant may indeed be advised.

        Djin
        Last edited by DjinTonic; 06-09-2022, 09:00 AM.
        69 yr at diagnosis, BPH x 20 yr, 9 (!) neg. biopsies, PCA3-
        7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
        6-06-17 Nodule on right + 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
        Nodule neg. for PCa
        Bone scan, CTs, X-rays: neg.
        8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
        SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
        pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma
        5% of prostate (4.5 x 5 x 4 cm, 64 g) involved
        Dry; ED OK with sildenafil
        11-10-17 Decipher score: 0.37, Low Risk:
        5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%        		 9-16-17 (5 wk) PSA <0.1
        (3 m ) 0.010
        (6 m ) 0.009
        (9 m ) 0.007 (nadir)
        (1 yr.) 0.018 (?)
        (13 m) 0.013 (retest)
        (15 m) 0.012
        (18 m) 0.015
        (21 m) 0.015
        (2 yr. ) 0.016
        (28 m) 0.015
        (34 m) <0.014
        (40 m) 0.037 (?)
        (43 m) 0.020
        (46 m) 0.018
        (52 m) 0.023
        (5 yr) 0.038
        (63 m) 0.036
        (66 m) 0.049
        (69 m) 0.054

        Comment

        • #5
          Michael,

          At this point you will discuss where you are and where you are going with your URO. If you are not Medicare, private insurance does not cover Decipher tests and may not cover adjuvant RT with a stable or undetectable PSA.

          Today there are some UROs that want to wait and do early SRT when the PSA starts to rise, other UROs the believe not doing ART misses potential cure, and other UROs who believe not zapping anything until PSA rises enough for a PET scan some they can pin point the treatment. All 3 can make compelling arguments.

          The nonograms suggest you have >50% chance of not having BCR at 10 years with no further treatment. So as Eastwood would say, “You feeling lucky”.

          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 &amp;lt;5%, Right side negative.

          3/6/19. Post surgery Pathology Report - Grade Group 4 Intraductal Carcinoma
          T3aNO, <1 mm non focal 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. (25 days)
          4/25/19. <.03. (2 months)
          5/25/19 <.02 (3 month)
          5/20/22. < .02 (39 months). T=37
          11/7/22. <.02 (45 months) T=54
          5/8/2023 <02​ (51 months)

          3 Part Modality Treatment Completed

          2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery his #41st in US.
          ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
          ADT - 5/19- 5/21 Eligard and Casodex.


          3 Part Modality Treatment Completed

          2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery #41 in US.
          ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
          ADT - 5/19- 5/21 Eligard and Casodex.

          ​

          Comment

          • #6
            It appears that BCBS, for one, does cover the Decipher test if the criteria are met.
            69 yr at diagnosis, BPH x 20 yr, 9 (!) neg. biopsies, PCA3-
            7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
            6-06-17 Nodule on right + 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
            Nodule neg. for PCa
            Bone scan, CTs, X-rays: neg.
            8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
            SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
            pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma
            5% of prostate (4.5 x 5 x 4 cm, 64 g) involved
            Dry; ED OK with sildenafil
            11-10-17 Decipher score: 0.37, Low Risk:
            5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%            		 9-16-17 (5 wk) PSA <0.1
            (3 m ) 0.010
            (6 m ) 0.009
            (9 m ) 0.007 (nadir)
            (1 yr.) 0.018 (?)
            (13 m) 0.013 (retest)
            (15 m) 0.012
            (18 m) 0.015
            (21 m) 0.015
            (2 yr. ) 0.016
            (28 m) 0.015
            (34 m) <0.014
            (40 m) 0.037 (?)
            (43 m) 0.020
            (46 m) 0.018
            (52 m) 0.023
            (5 yr) 0.038
            (63 m) 0.036
            (66 m) 0.049
            (69 m) 0.054

            Comment

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