Hello friends,

It’s Scared Wife (Stephanie) here again. I made a signature with my husband’s stats.

We have our first visit with his surgical oncologist at Yale tomorrow, and I was hoping you could let me know if I am missing anything. I am going to ask:

Is his three month post PSA of <0.04 considered undetectable? Quest Diagnostics said that was the lowest their machine could read.

Should we establish a relationship with a Radiation Oncologist so we are set if we need it?

Should we have a Decipher test?

Should we ask for monthly PSA’s in the short term?

If this is undetectable, could it be a masked value from remaining half life Lupron (three mos. ADT started 5/25….should have ended 8/25.)?

Why did the seminal vesicle involvement bilaterally show up on post op pathology but not on any scans?

They were not able to grade pathology based on ADT treatment effects, but the surgical report said the prostate was in an intact capsule and the seminal vesicles were grossly unremarkable. There was no ECE or positive margins. Perineural invasion and cribriform were present.

Is there anything I am missing or should ask in addition to this? Thank you so much. I hope you are all experiencing some positivity in your journeys. I follow this forum closely and check in on you wonderful people.

Thanks again.

Stephanie

Thank you Steven. I will ask about getting his testosterone checked. Take care, and have a wonderful holiday!

From what I gather, the pT3b path staging was because of the positive seminal vesicles. Nothing showed up on the MRI and they looked normal to the eye ("grossly unremarkable") after removal, but there must have been a small amount of invasion by the cancer on both sides that was discernable only under the microscope. Sometimes growth out of the prostate can be seen by the eye as abnormal or feel friable to the touch; other times the breech is microscopic, wherever it occurs. An MRI has a limit of resolution, which is why men with unremarkable MRIs are still advised to have a biopsy when there is a strong suspicion of cancer.

I would discuss with his doc whether adjuvant therapy is indicated, given the seminal vesicle involvement, the presence of cribriform pattern, and that your husband's final Gleason score could not be determined, but involved pattern 5 as established in the biopsy. A Decipher test could be helpful with this decision, especially if the advice you get about adjuvant therapy is not convincing one way or the other. (I believe there is a checkbox for "previous ADT treatment" on the Decipher ordering form, but you may want to check whether, in case of ADT treatment, they want the biopsy slides sent for testing in addition to the RP tissue). Or, if a PSA-monitoring approach is advised rather than adjuvant therapy, a Decipher result of high risk for mets might lower the PSA threshold at which salvage radiation is begun.

You may want to expand the post-op findings in your signature: the pre-op imaging and biopsy become less important when there is an RP report. For example, we know there were no positive lymph nodes found, because of the first "N0" in the staging; however you didn't specify the number of nodes removed (the more nodes removed and examined, the more weight you might give a negative finding). I believe the second "N0" should be "NX" since it refers to distant metastases and I presume no surgery other than the RP was performed. So the staging in the report should, IMO, be pT3a pN0 pNX.

Please keep us posted--we learn all the time, too. All the very best,

Djin

Maxwellcatmom said...
Cyclone and Djin,

.... My husband had 14 nodes removed including periprostatic. ...

I stand corrected: the "M0" path staging is correct if some of the nodes removed were farther than usual for an RP with an extended lymph node dissection (it's the first time I'm seeing it in an RP path report).

Djin

Duck2 said...

...
Should we ask for monthly PSA’s in the short term?

No, 3 months I for the first year, then every 6 months is enough.
...

Although a definitive Gleason score couldn't be established post-op because of the ADT, it has to be assumed--based on the G9 biopsy--that it would likely have remained 9. I would be very surprised if any uro would be OK going to a 6-month PSA schedule after just one year with a G9 and SVI+ even if the PSA still undetectable. I had G9 pT2 cancer with no adverse findings and a low-risk Decipher score, but my uro didn't approve relaxing the 3-month schedule for several years post op. But of course his future testing schedule isn't of paramount importance at this point.

Djin

Stephani,
Congrats on the <0.04. By definition, the appearance of the "<" means undetectable on the test they used. There are tests that go as low as <0.006--I think it's the ultra-low test that LabCorp uses. You can ask about that.

Obviously, he will have a follow up visit soon with the Surgeon--and you can ask many of these questions there.

Yes, I'd ask for a Testosterone test, just to see if the ADT is past. The path report is actually pretty good, given where you started, and you're likely on the 3 month test schedule for at least a couple of years. This is the other side of treatment, now. It's test, wait, test, wait, test wait. After a year or two, you may go to 6 months.

For now, I would be celebrating the non-detect--and hopefully have a good visit with the Dr. to talk about the specifics: What does HE think about the SVI and Cribiform cells? Does he think his work is done and you'd be better off with an MO to manage things going forward?

To me, the path report (Even without a final G-score) is way better than it could have been. There are no indications calling for immediate adjuvant treatment. So, get him healed up, and live!

Stampede said...
Hi Stephanie. I hope the consultation went well for your husband.
Reading your previous thread, I caught your comment about hoping for the SVI to be intraprostatic. You mentioned with no ECE and normal appearing seminal vesicles this could be the case. This is a very good point. You must have seen the research by Epstein and Partin showing intraprostatic SVI should not be called SVI at all since these patients fare much better statistically. Their definition of true SVI included penetration of the SV muscular wall or involvement of the extaprostatic portion of the SV. Your husband's ADT may have limited the pathology in the examination of the SV's but it sounds like the only indication of SVI was microscopic - more reason for optimism. Also, among patients with pT3b, those with clear SV's on MRI fare better than those that show SV Involvement on MRI.
I geeked out researching SVI last year as my MRI showed two PIRADS 5 lesions, both with ECE and bi-lateral SVI. Fortunately my post surgery pathology showed no adverse findings. But I know how worrisome this can be.
The <0.04 PSA is also wonderful news. Time to relax a bit and enjoy the holidays.

That foundational work by Epstein and Partin was done nearly a quarter of a century ago. Pathologists today are on the same page when assigning pT3b (seminal vesicle invasion):
_____________________________
"Pathologic TNM staging of prostate, AJCC 8th edition

Primary tumor (pT)
pT2: Organ confined
pT3a: Extraprostatic extension (focal is < 1 high power field in 1 - 2 slides, multifocal is more) or
    microscopic invasion of bladder neck (in thick muscle, no adjacent nonneoplastic glands)
pT3b: Seminal vesicle muscle wall invasion
pT4: Invasion of external sphincter, rectum, bladder, levator muscles or pelvic wall"
_____________________________
As I mentioned above, when surgery is the primary treatment, MRI and biopsy suggestions of adverse findings lose much of their significance once the post-op path report is complete. In your case the MRI indications of SVI were not borne out when your prostate was examined. The reverse was true for Maxwellcatmom's husband: the MRI was not suggestive of the SVI that was present bilaterally when the prostate was examined.

I'm not saying the path report should cause undo worry, but the combination of Gleason grade and adverse findings (G9,SVI and cribriform pattern) should be given due respect in risk evaluation and in drawing up a game plan going forward.

Djin

Stampede said...
Hi Djin, Your points are well taken. Stephanie's husband has findings that are concerning. What isn't clear is precisely what caused the SVI finding. The surgery report stated the "seminal vesicles were grossly unremarkable". This along with an intact prostate capsule and no ECE could indicate intraprostatic SVI. The details here are important. I made a guess in saying perhaps the ADT in this case made those details fuzzy.
I gave weight to Epstein's old article because I just haven't found any research that refutes it.
If Stephanie's husband does need further treatment, perhaps they should have Epstein take a look at the pathology to see if the SVI meets the modern definition.
I didn't mean to imply my case had anything to do with the case of Stephanie's husband. I was just trying to say I understood.

Indeed, Epstein was setting out the criteria that was adopted into the pathology standard. "Grossly intact" refers to initial inspection by the naked eye unaided by any magnification. However, microscopic examination counts too. I quoted the TNM stating criteria because it makes it clear that intraprostatic SVI alone does not qualify for pT3b. SVI is simple the observation of malignant cellular architecture in the seminal vesicles.

However, as I and other suggested, a review by Dr. Epstein of the biopsy and RP tissue would be in order, given the ADT treatment and the need to rely on the biopsy for Gleason scoring. By D'Amico's standards, men who are G9 with even one major adverse finding after RP are very high risk and should be advised about RT +/- ADT being part and parcel of their primary treatment. My uro/surgeon made this clear to me after my G10 (5+5) biopsy when we were discussing treatment options. At a visit a few years later, he told me that if I had had only lymphovascular invasion (an adverse finding entirely within the prostate!) with my G9 (4+5) pT2 N0 staging + negative margins, he would have advised adjuvant RT for me without question.

Djin

Your husband needs a healing period in any case. I think getting other expert opinions is worthwhile, even if in the end he stays with his current doctor.

Djin

Thank you also Halbert,

We will be enjoying these holidays for sure! I appreciate your input!