Update, pathology and questions

Hi all. I received my surgery pathology and have some questions.

Situation: Diagnosed in October 2017 (MRI, two Pirads 4 Lesions, followed by fusion biopsy) with Gleason 6 relatively low volume and suggested for active surveillance with next step to come back in 6 months for a PSA test (MSKCC). My very high PSA density had me worried that something was being missed. Second opinions (multiple) came back higher volume at 3+4 with relatively minor (5%) pattern 4 with recommendation to treat. I have been reading anything I could get my hands on and just wasn’t comfortable with the error margins in any predictive “models” for my case and agreed with treatment approach. 57 yrs old.

Treatment: Was open to any treatment approach but knew I had a bias towards surgery and that is where I landed after a great deal of research and all the things one goes through for these sort of things. Nerve sparing robotic surgery (NYU) and my recovery is going well. Excellent experience with team. Dry immediately. My expectations are very low on the ED front so hopefully I will be on the upside of that.

Results: 2.5 cm tumor in right and left Apex, 3+4+5 (30% pattern 4), Extensive Extracapsular extension (left and right Apex), 1 cm tumor in Base, 4+3+5, Tumor invades into bladder neck(BNI: present), Perineural Invasion, Resection Margins and Seminal Vesicles clear, 0/10 lymph nodes; pT3a

Surgeon briefly mentioned radiation and then suggested we follow PSA and respond accordingly.

Questions:
1. Am I now pretty much in “wait and see” mode with PSA or is a more active approach with adjuvant radiation warranted or an option?
2. If not, for folks in similar situations when would you start connecting with a radiologist to at least have someone on the ready in the event needed?
3. Any other observations on my pathology where I could draw on your experiences?

Thank you!! (my signature seems to not want to show up when I preview but hope it does when I post)
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August 2017: PSA 10.5 (5.25*2 given finasteride/propecia), FPSA: 9%
August 2017: MpMRI 2 lesions PIRADS 4 one in Distal Apex, Prostate size: 16cc
October 2017: Biopsy G6, 3/16 cores pos., all RHS
November 2017: 2nd opinion pathology: 4/16 cores pos.; G(3+4) 60%, G(3+4) 20%, G(3+4) 15%, G(3+3) 5% LHS

Post Edited (AJMan) : 4/8/2018 6:33:22 PM (GMT-6)

Hey AJ, yes, you're pretty much in wait and see mode. Your job for now is to get back in shape and heal. Even if you wind up needing additional treatment, they can't do anything for a while--so that's that. Usually you'll get a PSA at 6 weeks that will give an indication of what the future might look like.

The goal is to get a non-detectable PSA. You've got a reasonable chance of hitting it. From now till then, try to relax and let yourself get healthy.

AJ, my take would be that the reality is not much difference except in definition between adjuvant and salvage. Either way, the additional treatment will have the goal of cure. With your challenging pathology, you've got a more difficult road than some--and you'll get through it.

Get stronger--eat well, take your vitamins and supplements, walk, walk, and walk some more. When you feel up to it, do more. You'll get back to where you were. And, if more needs to be done, you'll be ready. If not--you'll still feel good.

You do not have gleason 3+ 4 +5 period...nary a gleason 5 cell to be found which makes the whole scenario much better for anyone...be honest gents...what were you thinking when you first read this post...beware internet forums...Info is passed around like this all on forums...all the time...then folks "innocently" and with a bewilded look an their face later .. I don't know where you got that information from ...Yikes...apologies for any honesty I may have injected and nary a correction from da rest...yeah I know...I know the signaturwe...which actually confuses the situation...I don't blame AJ or the forum...Its just China Town Jake....Hey I don't mean being the bad guy...its kind of like the ...shop steward...some one has to take the heat when "steaks" are made...right up my alley been doing since the first time some one cheated playing agates...as a tyke...no...not marbles...east coast agates...wid chunkarollas...

"1. Am I now pretty much in “wait and see” mode with PSA or is a more active approach with adjuvant radiation warranted or an option? "

Yes. There is no risk to waiting 3 months for a uPSA. ART and treating at very low PSA has similar probabilities of success. As long as there was no positive margin at the base, there is no point to ART. You have to wait a few months for healing anyway.

2. If not, for folks in similar situations when would you start connecting with a radiologist to at least have someone on the ready in the event needed?

You can wait until after your 3-month uPSA. If it is persistently elevated then, it will be a good time to meet with an RO.

3. Any other observations on my pathology where I could draw on your experiences?

The tertiary 5 is concerning, but hopefully he got it all.

AJ thank you for proving my point...If you can show me where on your initial thread the information you just shared is anywhere...You may send me a big crow which I will barbeque in the whiskey of your choice and eat feathers and all...to the rest...some one tell me with a straight face that they knew the details of this situation in the same way as you do now...OK AJ no blame no shame it just as I it said goes to the danger of communicating and believing what you read/hear...I would apologize for any sarcasm...but can not in good faith...as it really can be instructive in our species good luck with your treatment logo

Logoslidat. I guess I could either ignore you or try to understand what you are saying and respond. Since you appear to be questioning the legitimacy of my post in some way I would like to ask if there is a forum manager or leader who can help here. I have been reading this post since I joined in October (and posted upon my diagnosis) and would have never expected to receive this kind of a response. I am recovering from surgery that I had on March 28th and was hoping to get both support and guidance from a forum I have come learn a great deal from and respect.

AJMan said...
Logoslidat. I guess I could either ignore you or try to understand what you are saying and respond. Since you appear to be questioning the legitimacy of my post in some way I would like to ask if there is a forum manager or leader who can help here. I have been reading this post since I joined in October (and posted upon my diagnosis) and would have never expected to receive this kind of a response. I am recovering from surgery that I had on March 28th and was hoping to get both support and guidance from a forum I have come learn a great deal from and respect.

AJMan, I had the same misunderstanding of logo a couple of years ago. I was infuriated by his seemingly mocking posts. But, then I saw how long he has been a member, and how many posts he has made. Over 5,000!

OK - he writes in a Haiku style of poetry. It is just his way of communicating. Please accept his good intentions. He is a major supporter of this board and those who come here for help. He's simply...well..different.

AJ,
Good Morning all I can add is what I advise most new surgery patients. If able start walking then do some more walking and along the way do some kegals you don't have to overdo them tho walking is critical to keep things moving and helping with the healing. It might also prevent blood clots. Sounds like your surgery went good see where you are in 3 months and go from there no use worrying about anything at this point. Oh and Logo don't worry about him sometimes I think his spell check went goofy but he means well and as I first looked at your post was wondering about the 3+4+5 not use to seeing that but after you explained bingo now it makes sense! Wishing you the best recovery!!

Larry

I am seriously touched...Its funny...I put you and TA on ignore...last night...then...after a bit...I reflected...ya know...I might have touched him{ side note...the only way we can touch the tip of a finger with that finger...is in a mirror...a reflection...an image of it...MichaelAngelo knew this as is reflected in the main fresco of the Sistine Chapel...y'all know the one} anyway be fore I rudely interrupted myself...I says to myself...suppose he posts some thing positive about me[which of course is something I would appreciate...even if outwardly it was negative...which it was not...well if he did...I would not know...and I would have missed out on writing this post...getting to know AJ better...and others of whom I would never have expected their own powerful reflections...funny yea??...and yes...I took TA off a short ignore...as well...we are all uniquely the same...trying to meet each others other...where it is...enough kumbaya...AJ I also gl9 4+3 tert 5...the 5 were 2 foci..which are small but...I'm coming up on 9 years post op.. try not to worry....concentrate on recovery..." sufficient unto the day is the evil there of"

Folks,, something I am unclear on and wondering if you can help educate me on. I am not sure how to reconcile/interpret bladder neck invasion and clear surgical margins in the path report.

Can you have bladder neck invasion without a surgical margin in that area? Does that mean there was evidence of bladder neck invasion but not at the margin where the surgeon cut? When I look at the literature on BNI (which is very limited) it looks like they are often equating bladder neck invasion with positive surgical margins. I am formulating a mail for my surgeon with open questions that includes this but thought someone here may have input that would cause me to either forgo or reformulate that question.

And just to be clear, I am following you advice, focusing on just recovering and not worrying much about this....

Thanks!!