Robotic Surgery

Hello everyone   I am 59 and had previously been diagnosed as having benign enlargement because of the usual symptoms i.e. frequency of urination, getting up in the middle of the night etc.   My PSA had been steadily climbing over the past 18 months and is now 3.7. Previous DRE had been unable to feel any tumour. So my Urologist organised a biopsy in May this year, which came positive for cancer (Gleason Score 9).   I am booked in for surgery on 20 July. During my consultation with the surgeon (a different Urologist) last week, he gave me a poor prognosis, saying that because of the grade of the tumour he thought that even if my surgical margins were clear there would still a 50% chance that some cancer cells have already escaped into the surrounding tissues and hinted that I may need follow up radiation therapy. My referring Urologist had assigned my clinical stage as a T1c. However this surgeon has predicted a pathological stage as either a pT2c or a pT3a. I was a bit despondent after hearing this, as I had thought there was a good chance that the cancer would be contained within the prostate and I may have had a chance of a "cure", given my relatively low PSA and the fact that the tumour could not be palpated.   I would appreciate the views of some of you who may have been in a similar clinical stage as me and what your outcome was.   Also, can anyone tell me: can they remove the prostate intact using robotic key hole surgery and if not, how do they determine with any accuracy the pathology and importantly whether the surgical margins are clear.   Thanks guys

Hi Ozbob, - You still have a chance that you could be "cured" although, realistically, the Gleason 9 has reduced it considerably. IF the Prostate Cancer (PCa) is fully contained, with ALL malignant cells entirely within the margins of the surgical incision, the Cancer will be removed with the excized Prostate. By choosing surgery you will have the benefit of the post-surgical Pathology Report which will best identify the true status of your disease at the time of your treatment. Only surgery provides this added benefit, which is particularly valuable in determining possible adjuvent therapy in cases of potentially more advanced disease.

Robotically Aided Laparoscopic Prostatectomy (RALP), DOES remove the entire Prostate with some surrounding tissue and will provide valuable information in making further INFORMED decisions based upon the Pathology findings, from examining it under the microscope and enhanced by appropriate "staining" where applicable. It could be that (following) adjuvent Radiation MAY be recommended, particularly if positive surgical margins are found to be present. Secondary radiation is usually administered at different levels than Primary Radiation. A Prostatectomy is essentially the same operation, with access to the surgical site being the major difference between RRP, RALP, RLP and RPP approaches.

Remember, that there are no 100% or 0% guarantees in PCa treatments and everything is a matter of statistical likelihoods (the "odds") so there is always hope for a "cure" tempered by the reality of the statistical odds involved. Such odds are produced by weighing the results from large GROUPS of men, with similar disease characteristics and cannot be directly transferred to any INDIVIDUAL patient. So remain optimistic!

If you will send me an E-mail request, I will forward you a talk by Dr. Peter Scardino, one of the recognized top experts in Urological Surgery, that you should find both interesting and encouraging, since it compares the long term results between Surgery and Radiation at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, where both departments rank amomg the best in the world. I hope this helps and good luck to you! - John@newPCa.org (aka) az4peaks

Post Edited (az4peaks) : 7/11/2011 7:54:56 PM (GMT-6)

Ozbob, we G-9 guys live in a different world from the G-6 and G-7 guys..I'm a little surprised in the 3 month wait before treatment, They usually try to fast-track us because of the high-risk characteristics..

My surgeon also gave me a similar prognosis as you have received. He even thought I might be a better candidate for radiation than surgery because of those 50-50 odds...As it turned out he was right, I have completed salvage radiation and am on hormone therapy also...

Today, the most recent studies have shown that the MOST EFFECTIVE treatment for high-risk PC patients is the combination of hormone therapy followed by Brachytherapy and beam (IGRT) radiation. The results of this study have been posted on this board. This treatment is not possible for everyone, you will be rejected if your prostate gland is too large... In some areas of the country, you will need to travel to find a treatment facility that performs this treatment..But it's worth the effort as it seems to deliver better outcomes than surgery for high-risk patients.

I chose surgery because I wanted the cancer removed and ALL the doctors I consulted with said surgery was worthwhile even if it failed to deliver a cure..De-bulking the tumor mass and being able to do a complete biopsy was worthwhile even if it failed...Also, a 50% chance is better than no chance and the door is still open for radiation treatment..I also learned that with G-9 guys, they usually recommend doing all three treatments regardless.. Unless that post surgery pathology is PERFECT they will probably recommend doing radiation and hormones as soon as possible after surgery, a one two three punch that gives high-risk guys their best chance and produces the best overall results..

Have you read any of the PC books by Walsh and or Chodak? If not, now would be a good time...The best of luck to you...

Welcome to the Otherside... Gald you made it ok...

Hi Ozbob,

Glad to see you're recovering well. Being a fellow member of the G9 club, I know that it can be hard to digest all the information being presented and understand the ramifications of proposed treatments. Here are a few articles you might want to read to help you better understand your pathology report, etc., and ask questions:

"Treatment strategies for high-risk locally advanced prostate cancer", http://www.nature.com/nrurol/journal/v7/n1/full/nrurol.2009.237.html

"Role of surgery in high-risk localized prostate cancer", http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2935705/?tool=pubmed

"Salvage Radiotherapy for Patients with PSA Relapse Following Radical Prostatectomy: Issues and Challenges", http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848745/

"Positive margins after radical prostatectomy: Implications for failure and role of adjuvant treatment", http://www.ncbi.nlm.nih.gov/pubmed/21775170

"Nine Decisions Before Electing RADIATION THERAPY After Radical Prostatectomy", http://www.prostate-cancer.org/pcricms/sites/default/files/PDFs/Is13-2_p8-17.pdf

As others have said, if your pathology report shows that the cancer was localized to the prostate with no other adverse findings, there is still hope that the surgery cured it. Even if you suffer recurrence, combined radiation and hormone therapy still offer chance for a cure.

I had surgery last August. My PSA was undetectable after surgery, although I had positive margins. While my oncologists recommended immediate radiation and hormone therapy, I elected have ultra-sensitive PSA tests, and wait until they indicated my PSA had returned before taking action in the hopes of a cure. Starting in April, my PSA began to rise and I have elected to begin treatments. At the time, my doctors thought my chance of recurrence was 50%; that was before the "Positive margins" study mention above came out, which shows a >70% chance for G9 with positive margins. I probably wouldn't have waited had I known that.

Take care and enjoy the lovely blue skies and warmth of summer.

Nellie

Thanks for the replies everyone.

I get the Path. report tomorrow.

If I am subsequently advised to begin adjuvant radiation therapy, when should this begin post op?

Howdy OzBob,

Good luck with your pathology report. Any adjuvant therapy would wait for your body to recover from surgery -- typically three or more months. If your post op PSA is undetectable and there aren't positive margins or EPE, you might opt to delay the therapy until it begins to rise in the off-chance that you've hit the cure jackpot. In that case you'd probably want to use the ultra-sensitive PSA test to catch any rise quickly

It is probable that adjuvant radiation would be accompanied by hormone therapy for 12 to 24 months, as this is now considered the "standard of care" for high risk patients. See the "Treatment Strategies" study I referenced above.

I am getting both, and my hormone therapy will likely be between 12 and 15 months, depending on how I tolerate it.

Take care,
Nellie

Hello everyone

Well, I got my Path report yesterday and it was better than expected.

The main content is as follows:

Tumour Stage:  pT2c pNO

Gleason Score:  Dominant nodule 4+3 = 7 + tertiary 5

                          Non dominant nodule 4+3 = 7

EPE:  Absent

SVI:  Not involved

Surgical Margins:  Negative for cancer

Lymph Nodes

Right pelvic (23): No evidence of malignancy

Left pelvic (17):  No evidence of malignancy

Anterior prostatic fat: No evidence of malignancy or lymp nodes

Lymphovascualr invasion: Present

Perineural invasion: Present

Prostatic intraepithelial neoplasia: Present

It seems that my GS has been downgraded (from initial biopsy) from a 9 to a 7. Can anyone tell me what a "tertiary" number of 5 means and its significance?

Also, can I get some views on the Perineural and Lymphovascular invasion and its significance.

Lastly, does anyone know what Prostatic intraeptihealial neoplasia is and its significance?

Thanks again guys for your informed comment.

Ps. Ausboy: I had by surgery at the RBH in Brisbane and it was robotic key hole.

 

Post Edited (Ozbob) : 7/27/2011 7:39:44 PM (GMT-6)

Hi Ozbob,

Grats on the downgrade of your Gleason score. I'll try to answer some of your questions if I can.

A. Tertiary Gleason 5

Regarding the tertiary score, here's an article that is right on point: "Presence of high grade tertiary Gleason pattern upgrades the Gleason sum score and is inversely associated with biochemical recurrence-free survival":

OBJECTIVES:

Tumor heterogeneity is a common finding and led to realization of a tertiary Gleason component (TGC) in prostate cancer. In an attempt to further investigate its prognostic value, we analyzed the association of tertiary Gleason pattern in Gleason score ≤ 7 tumors with pathologic stage and biochemical disease-free survival.
MATERIAL AND METHODS:

A total of 331 radical prostatectomy specimens were analyzed retrospectively. The primary, secondary, and the tertiary patterns were evaluated by reviewing all of the pathologic slides. TGC was defined as Gleason grade pattern 4 or 5 for Gleason score < 7 tumors and Gleason grade pattern 5 for Gleason score 7 tumors. The pathologic prognostic factors, (extraprostatic extension, seminal vesicle and lymph node invasion, surgical margin status) of Gleason score < 7, 3+4, and 4+3 tumors with or without TGC were compared. Biochemical recurrence-free survival (BRFS) was calculated using Kaplan-Meier method with log rank test, and the influence of TGC was assessed in a Cox regression model.
RESULTS:

TGC observed more frequently with higher Gleason scores (21% of the GS < 7 cases, 23% of the GS 3+4 cases, and 58% of the GS 4+3 cases). In terms of adverse pathologic prognostic factors and BRFS, GS < 7 tumors with TGC behaved significantly worse than GS < 7 tumors without TGC (P = 0.01 and P = 0.001, respectively) with properties similar to GS 3+4 tumors without TGC. Gleason score 3+4 and 4+3 tumors without TGC were statistically similar and had better features than corresponding tumors of same Gleason score with TGC. Furthermore, Gleason score 7 tumors with TGC had similar features with GS 8-10 tumors. During follow-up, 73 (22%) subjects had PSA recurrence. In the Cox regression model TGC was an independent variable for BRFS (HR = 2.63, 95% CI = 1.39-4.98, P = 0.003).
CONCLUSION:

According to the present study, 3 different prognostic groups were observed; good prognostic group: GS < 7, intermediate prognostic group: GS < 7+TGC, GS 3+4, and GS 4+3, and finally bad prognostic group: GS (3+4)+TGC, GS (4+3)+TGC, GS > 7. Presence of a TGC appears to upgrade the total score and adjuvant treatment decisions may further be refined by considering the tertiary pattern.

B. Perineural and Lymphovascular Invasion

In my review of the literature, there are different opinions about whether these indicate a greater likelihood of recurrence. A study by Huang said perineural = yes; lymphovascular = maybe. Other studies say no. I've also read that perineural invasion only matters if the cancer excaped the prostate and invaded the exterior nerves. The study mentioned below said they were not useful in determining chance of recurrence.

C. Prostatic Intraeptihealial Neoplasia

From what I've read, PIN is a precursor to cancer, so it is primarily useful if detected in the biopsy. One study had this to say about PNI, LVI and PIN:

Although presence of PNI and LVI in RALP specimen correlated with multiple adverse clinicopathological factors, it did not predict biochemical recurrence, thus limiting its clinical usefulness. HGPIN (high-grade PIN) was not significantly associated with the clinicopathological characteristics studied.

See: "Significance of Perineural Invasion, Lymphovascular Invasion, and High-Grade Prostatic Intraepithelial Neoplasia in Robot-Assisted Laparoscopic Radical Prostatectomy", http://www.ncbi.nlm.nih.gov/pubmed/21660497

Hope that helps.

Nellie

Hi Everyone

Thanks for the replies.

If there is anyone else who would like to give an opinion, please feel free.

I've finally worked out how to post my signature, IT is not my strong point!

Thanks guys