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JayMot Pathology - Not Good

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Posted 6/8/2016 2:07 PM (GMT -5)
Hey guys and gals,

Listed below is my pathology report from my June 1 surgery. It isn't good. G7 (4+3) Positive margins and EPE, no seminal vesicle or lymph spread.

It's all a lot to take in now as I am still healing. I need this to sink in and then I will determine my next steps. My first PSA test is scheduled for the end of August. Can PSA ever go to undetectable with this pathology? Can a pathology like this somehow keep me from further treatment for some time, or will I need it right away? Is all future treatment all determined by PSA?

My surgery was at Univ of Pennsylvania and I'm sure they will direct me to their Abramson Cancer Center for further treatment. Does anyone know of a better place in Philadelphia metro area? How about highly respected RO's or MO's in the Philly area? Before the PSA test, I would like to line up my care team going forward, so if I need to jump start treatment, I can.

This is upsetting and all I can think of is negative thoughts right now. I'm sure there are some out there with similar pathology that are doing well many years down the road. Can I still fight this to win, or is that fight over? I feel, based upon the info I had going into surgery, that I had a decent chance, not a great chance, to have a better outcome. I flipped the coin, called "heads" and tails came up.

I want to thank everyone for their support from early Feb until now. Your kind thoughts and well wishes are appreciated. However, the knowledge learned on this forum was invaluable and enabled me to discuss my case intelligently with every medical professional I've come across.

i plan on healing over the next month or so then enjoy a little vacation then onto the first PSA test,

J

1. ANTERIOR PROSTATIC FAT:
Benign mature adipose tissue.
One minute lymphoid nodule,no tumor seen.

2. LEFT PELVIC LYMPH NODE:
Four small lymph nodes,no tumor seen.

3. RIGHT PELVIC LYMPH NODE:
Three lymph nodes,no tumor seen.

4. PROSTATE GLAND,ROBOTIC RADICAL PROSTATECTOMY:
Prostatic adenocarcinoma,Gleason Score 7(4+3).
Gleason parttern 4 occupies approximately 80% of the total tumor load.
Tumor involves both the right and left lobe of the prostate gland.
Unilateral extracapsular extension present,right posterior capsular and
right apex,4F,4DD.
Rare tumor glands are focally present at right apical inked resection
margin,4CC.
The inked capsular margin is free of tumor,but very close and less than
1,0mm away from the inked right posterior capsular margin,4F.
The inked bladder neck margin is free of tumor.
Tumor occupies approximately 25-50% of the specimen submitted.
Bilateral seminal vesicles,no tumor seen
Perineural invasion present.

Prostate Size
Weight: 37.0g
Size: 4.5x 3.6 x 3.7 cm

Lymph Node Sampling
Pelvic lymph node dissection

Histologic Type
Adenocarcinoma (acinar, not otherwise specified)

Histologic Grade
Gleason Pattern

Primary Pattern
Grade 4

Secondary Pattern
Grade 3

Tertiary Pattern
Not applicable

Total Gleason Score: 7

Tumor Quantitation
Proportion (percentage) of prostate involved by tumor: 25-50%

Extraprostatic Extension
Present
A few foci,unilateral,right posterior capsular and right apex

Seminal Vesicle Invasion
Not identified

Margins
Margin(s) involved by invasive carcinoma
-right inked apical margin

Treatment Effect on Carcinoma
Not identified

Lymph-Vascular Invasion
Not identified

+ Perineural Invasion
Present

Pathologic Staging (pT3a,No,Mx)
Posted 6/8/2016 2:17 PM (GMT -5)
Jay:

Your pathology is pretty much identical to mine.
It could certainly be worse.

At this point, I suspect it will be a case of just checking your PSA every 3 months. As I was told, anything can happen. For me, they did not want to do radiation, but said I should wait.

I did but eventually I had to do radiation.
One never knows. You are in that grey area.

I will say that although for me I failed the surgery (you might not have) and I failed radiation, I am still doing reasonably well, doing intermittant HT.

I was dx. in late 2009.

Mel
Posted 6/8/2016 2:43 PM (GMT -5)
Sorry for the path report. You can wait to see what your ultrasensitive PSA says. Usually done at 3 months, but 6 weeks might not be a bad idea. They have to wait at least that long for healing to occur.

- Allen
Posted 6/8/2016 2:51 PM (GMT -5)
What Allen said - wait for the PSA test.

and listen to Mel, even if the worst is true you've got a lot left to fight with.

Rest and heal,
Andrew
Posted 6/8/2016 3:10 PM (GMT -5)
JayMot, you said:

"Can I still fight this to win, or is that fight over?"

JayMot, this fight is NEVER over!

The outcome so far is not what you expected or wanted, but if this forum and the people on it have ever taught anybody anything, it's that dire prognoses are NOT conclusive, and that there are many, many treatments and options still available for even the most concerning diagnoses!

We have members here who are Gleason 8s, 9s, who are still getting up in the morning and living their lives years after being told their situations were terminal. Well, they weren't.

We have this one fellow here, goes by the name of Todd1963, who is just a shining example of someone who got an abysmal, you-won't-last-long diagnosis years ago, who has now been around YEARS following that gloomy prediction, and is living proof (yes, exactly that, living proof) of how life can go on, and go on well, following even the most worrisome of diagnoses.

Todd, are you there? If so, please do post now and tell this man just how possible it is not only to survive this thing, but to thrive as well! Tell him the numbers you had, and just how you have come to live above this beast.

"Can I still fight this to win?" JayMot, you BET you can!
Posted 6/8/2016 3:18 PM (GMT -5)
While the pathology report "isn't good," it does closely mirror your clinical diagnosis.

The fight is not "over." I saw a great quote from another cancer survivor once; I liked it so much I wrote it down:
    “What statistics tell you is whether you’re in a great big fight, a medium-sized fight, or a little fight. People win and lose all three, so it just tells you what your fighting mind-set is.

    “It tells you what level of risk you’ll take in treatment. It informs things. But I don’t think it’s very helpful on the ultimate question: Will I stay or will I go?”



Fox Chase is a leading CCC. Here's a starting point for MOs: https://www.foxchase.org/find-doctor?name=&specialty=181&dept=271&lang=All&op=Apply+Filter%28s%29

Post Edited (JackH) : 6/8/2016 2:21:25 PM (GMT-6)

Posted 6/8/2016 4:33 PM (GMT -5)
Jay, sorry to see this post. Not only for the positive margin and EPE, but for your comment about thinking only negative thoughts right now. But i think thats only natural, we are after all humans with emotions, like fear, but also like hope.
Give yourself a day or two or three to be upset over this. Then pick your ass up off the floor and get ready to fight the fear. And the disease. There are guys here with the same, or even worse diagnosis than you, as 81gyguy said, who are doing just fine thank you. Todd1963, just celebrated 10 years of battle. And from his blog, and from his posts, i think he would tell you his life is in many ways, richer for it.
Much to the chagrin of your enemies, if you have any, you are going to be around for a long time.
So hang in there, and try to think positive. There is a future for you, and likely a good one.
Posted 6/8/2016 4:45 PM (GMT -5)
Jay,

Certainly not the report you wanted. As I read through it, though, I see a lot of encouragement:

The tumors, while substantial, are contained within the surgical margins. PNI is one of those things, as I recall other threads where they are discussed, that is full of divided opinion over it's value. Maybe, maybe not.

The big thing is that a PSA at 6 weeks shows the trend, it is likely not going to be zero....but it should be low. It takes time for PSA to bottom, and most docs won't head for adjuvant therapy until 3 months after surgery...not only for PSA to bottom, but for surgical healing to progress to a good level.

It's good to get your ducks in the row in case you need them. There is a strong possibility you won't need them, at least not for a long time.
Posted 6/8/2016 4:48 PM (GMT -5)
JayMot
As others have said it's too soon to tell how well your surgery worked until you have PSA results. But please see my signature. I was 3+4, not 4+3, and I did have SV involvement at just about your age. I'm still here and doing well at age 70. I eventually needed SRT seven years after surgery, but that knocked it back to undetectable (0.00) for five more years.

Jim
Posted 6/8/2016 4:57 PM (GMT -5)
Hey Jay Man. Welcome to the fight amigo. Your situation isn't rare or unusual. Tons of guys in here have been through very similar plans and early intermediate results. More times than not, those stories end very well, and as far as I can tell, they are all here cheering you on, so I don't need to tell you how successful their treatments have been.
You're still on the same road amigo, and it still ends with success!
Posted 6/8/2016 5:20 PM (GMT -5)
Hi Jay, rough read... Take it easy and work on getting better post op first and then wait for next PSA. Take care. -JR
Posted 6/8/2016 5:35 PM (GMT -5)
Jay,

I know you wished for a better path report, but positive margins doesn't always mean future problems. You can go many years before you PSA hits the infamous 0.2. My oncology urologist said that 20% of patients with positive margins remain with a PSA less then 0.2 and never increases remaining asymptomatic. He also mentioned that is it better to have a positive margin then a delectable PSA with a positive margin. Only time will tell.

Aft my first post surgery PSA of being undetectable, I went 2 years with 0.1 and because of a screw up in a fluke PSA test I started radiotherapy. It wasn't until a week later when another PSA test the morning prior to radiotherapy did I found out my PSA was still 0.1.

As another friend that had cancer told me, "just chill out and don't stress out over something you don't have any control over."
Posted 6/8/2016 6:48 PM (GMT -5)
Jay,
Looks like you went into surgery as a 4+4 so after path report your actually a 4+3 so it's actually better than before surgery. I have nothing to offer regarding the future but my experience so far is I don't even know I'm in a fight....doing what I can to take out an invisible opponent. My intraductal is so rare I had a hard time even finding a team that would formulate a treatment plan which has yet to be seen if it works but were giving it the best shot we can. John Hopkins had 79 cases like mine out of over 40,000 and not one of them turned out good. Guess what I'm trying to say is there is a standard of care for you and although everyone reacts differently there is a good path that is proven for the majority of them with a very positive outcome. I'm not fighting...I'm living. I have 8 children who rely on me daily and for me this is a nuisance and slight disruption. I can totally relate to the negative thoughts as I'm sure many here can also but try and look at all the guy's out there and on this site who have totally kicked this thing in the ass.
Posted 6/8/2016 7:57 PM (GMT -5)
Jay

Glad you are here- I am similar to you. Started having symptoms at age 55. Did not do what I should have done by going to dr. At age 57 PSA was 4.1- had biopsy came back 3+4=7- Did DaVici came back EPE+- Neg margin,
first PSA was.005. PSA bounced around for nearly eight years. Finally hit .06. Urologist and RO pulled the trigger for SRT. I have been <.006 for over a year. I am nearing nine years. So yes you still do have a chance at winning or at least sustaining a life for a good long time.

Stay here learn, share and be encouraged.
Posted 6/8/2016 8:32 PM (GMT -5)
Ive seen worse and better.. Its good enough to give you lots of hope and bad enough too keep you toggled to your medical institutuion if you choose... Yo will definitly be encourged to to all kine stuff that you may not need...at this point in time...My advice is live your life and wait for some psa tests to define your condition... google the term foci sometime and read walshes chapter on positive margins....get the slides done by epstein you could get a downgrade...A sharper eye may see it as a 3+4...Sorry some paths will go fro the worse intepretation others will go for "nicest " I sense that epstein may "paint what he sees" minus a dog in the fight...things to ponder...or not...
Posted 6/9/2016 8:59 AM (GMT -5)
Hi Jay,

Well, I can relate to getting a report that is worse than you were expecting or at least hoping for. I remember how I felt when I got my report that I was not contained, even though the main reason I had surgery ( as opposed to other treatments) was because of the hope of a cure if I was contained. Which, despite my G9 and PSA >10, was my extremely experienced surgeons gut feeling after he gave me another DRE. He felt there was a fairly good chance it was contained, and if so the surgery would offer me a cure pretty well confirmed by a path report that would tell me about things like SV and LN, yay or nay. So I went for it, even though the thought of the possible or even probable SEs made me nearly throw up.

So my heart really sank when I got the call that I was NOT contained, had a positive margin plus SV+. Though I was too crushed to see any positives at the moment, at least I knew I was not LN+, and got a minor down grade from 5+4 to 4+5. Then I got another shock when I got it together enough to ask " OK, what's next" and getting the answer "nothing, at least not if and when PSAs go up". I figured there would be immediate RT and HT.

But I can relate to how you might be feeling. Still, take heart, it does not seem to me all that bad relatively speaking. Just not the best possible. But still, you already knew you were G7. So no change there, no upgrade! And you are good with your nodes and SV, and that is a big plus. My understanding ( could be wrong) is that positive margins are not in the same ball park as are LN or even SV invasion as far as prognosis ( especially considering survival) goes, and you are in good shape as far as the others go.

So all your results tell you for sure is that, like the rest of us, you will want to keep a close watch on your PSAs for quite a few years going forward, but you wer probably going to be in the boat any way. It is great news that you were not upgraded and are SV- and especially LN- . YAY!

urology.jhu.edu/newsletter/prostate_cancer410.php

Somebody said...
And, even if the surgical margins are positive, this does not necessarily mean that the cancer is left behind.

drcatalona.com/quest/quest_spring03_3.htm

Somebody said...
Radiotherapy is best suited for patients with positive margins and/or extracapsular tumor extension, because they are more likely to have a tumor recurrence in the bed of the prostate gland.

However, not all patients with these findings require radiation therapy, and, in fact, most will not have a tumor recurrence, even without radiotherapy.

bmcurol.biomedcentral.com/articles/10.1186/1471-2490-14-86

Somebody said...
Among men undergoing prostatectomy, 479 (38%) had positive margins. In the multivariate logistic regression analysis, period, clinical- and pathological T stage, Prostate Specific Antigen (PSA) level, Gleason score and percentage of tumour in the prostate were significantly associated to positive margins. Ten-year prostate cancer-specific survival was 96.6% for the negative margins group and 92.0% for the positive margins group (log rank p = 0.008). In the Cox survival analysis adjusted for tumour characteristics, surgical margin status per se was not an independent prognostic factor while age, pathological T, PSA level and Gleason score remained associated with prostate cancer-specific survival.

Posted 6/9/2016 9:11 AM (GMT -5)
Wait! Earlier I said "But still, you already knew you were G7."

But I just re-read your signature and I see a 2nd opinion upgraded you to a G8.

Bro, you had a significant down grade via the surgical path report! A down grade plus you KNOW you are SV- and LN-, neither of which was guaranteed! Time to celebrate!

I think tonight I will have an extra beer for you!

Bill in MS
Posted 6/9/2016 9:38 AM (GMT -5)
Jay,

I sincerely hope you are reading all of this great advice and testaments of longevity with a disease that does its best to change lives.

Hope is a wonderful thing. Never lose it. Without hope you have given up and with this disease you must be a Muhammed Ali in the Prostate Cancer ring.

My husband finally got his catheter removed Tuesday after 3 1/2 weeks of carrying it around with him. We do what we have to do to kill this beast, but we do it with hope. With the help of those who have already been there/done that we keep our hope because they have shown us the way, shown us that all things are possible.

Don't you have a graduation to attend? Just as your child never thought this day would come, he kept his eye on the prize and kept hoping to the future doing all he could to get there. That is what you will do. Keep your eye on the prize and do what you have to do when you have to do it. Don't look for trouble where there isn't any, but don't stick your head in the sand either. Be diligent about your check ups and be ready to nip it in the bud if and when necessary. Isn't this why both you and my husband did the surgery first? So that radiation would be available should the need arise? Well, if it arises you will be ready. But you must hope and believe that your surgeon did a great job and that your faith in his abilities was well placed. It is up to your body now, but don't give your body the edge by believing in the worst. Believe for the best. Hope for the best. And live life to the fullest!

Prayers go with you.
Posted 6/9/2016 10:04 AM (GMT -5)
Jay,

My thoughts and prayers have been with you as I knew you were headed into surgery. Well, maybe not what you expected but not as bad as it could have been....

My husband started his radiation a little less than 3 months after his Pt3b diagnosis after surgery (one seminal vesicle involved no nodes positive margins). His PSA was < .01 on the sensitive test for years and then only now is creeping and we are about 5 years out. He had no side effects from the radiation other than slight rectal bleeding.

Hang in there and give it time. Attitude is huge. Investigating a team is a good idea. Our RO is in South Central NJ and is loved. Probably too far for you.

Judy
Posted 6/9/2016 11:17 AM (GMT -5)
Wife_on_alert,

I actually live in central jersey. Can you email me your RO information?

J
Posted 6/9/2016 1:21 PM (GMT -5)
Small world. I live in Central Michigan (<g>)

Mel
Posted 6/9/2016 4:39 PM (GMT -5)
And I live in southeastern Illinois. :D
Posted 6/9/2016 5:40 PM (GMT -5)
Hi JayMot -

The title of the thread worried me until I read your post.

As I recall our email exchange you were concerned that you might end up Gleason 9 as the 4 was upgraded to a 5.

" I am nervous and scared. They say 30% of surgeries result in an upgrade in pathology. So, that would put me at least a G9 coming out."

to which I replied

"I highly doubt you would be upgraded to G9, perhaps a few more 4+4, 4+3 instead of 3+3. The good thing with surgery is you get a true pathology rather than random sampling. As a G9, that was not an option for me"

While you no doubt were hoping for a pathology of 3+3, that was a long shot.

As others have said this is actually a downgrade from second opinion 4+4 to actual 4+3.

One of the reasons for choosing surgery was to a get a definitive pathology which you accomplished.

So you fear of Gleason pattern 5 is diminished and many guys that are G7 (4+3) go years before having to do radiation.

While initially a disappointing pathology from the best case scenario, you have time to monitor the PSA and continue to keep abreast of the emerging technology improvements on how to treat our disease.

Like all of us you need to boss the disease rather than letting it boss you.

Even though I am G9, compared to what guys like Todd1963, Gunner34, and SteelGuy have been through and succeeded, I am eternally optimistic. Saw this post on another thread from Ray the SteelGuy

"I too have been on the path for a while (four years now). Lots of life to enjoy and I chose to find the best care I could, to keep asking questions until I found the people who were working at the highest levels on my specific needs.

I think of it as a mountain I find is on my path in life. Wasn't expecting it, but just got to climb it anyways. Still get to enjoy the scenery, friends, family, and good times ... Always a surprise where life takes us.

Ray"

Actually meeting these guys in person at semiannual GFMPH gatherings is even more encouraging. You can do a forum search on GFMPH to figure out Good For A Man's Prostate Health, next one last week of Sept in Rochester NY, but for the moment just get ahead of the beast.
Posted 6/10/2016 1:39 PM (GMT -5)
Jaymot,

Hang in there man, focus on the short term recovery. I know the prognosis wasn't what you were hoping for from a pathological perspective, but it's way too early to tell what your long term prognosis will look like. In the meantime, stay frosty brother, and by that I mean stay positive and hopeful, plan your recovery and work your plan day to day for now. Enjoy life while you can, live every day to the fullest! cool

Abramson Cancer Center has some good RO's so I would definitely recommend a consult if/when the time comes. I will second FCCC (Fox Chase), specifically Dr. Horwitz there, who is my RO there. CTCA also has a Philly location (www.cancercenter.com/eastern/), and MSKCC up in NYC isn't too far away from you either. Lots of options given your central NJ locale if it becomes necessary.
Posted 6/10/2016 9:46 PM (GMT -5)
Let me second the suggestion....

Have it sent to JH for a second opinion. They lowered my margin from 5mm to 3mm. They also told me the Gleason score on the margin was all G6. (Something the local path didn't mention)

You want as much information as possible.

I don't know what "rare tumor glands" means.

A secomd opinion could change what you're thinking may be going forward. You're doctors office may already know where to send it. If they don't it's a simple phone call to find out.
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