Scaredwife

This is my first post though I have been reading through the forum. I am so glad there is a forum like this. I will figure out how to do a signature. My husband was dx with high risk Prostate Adenocarcinoma (acinar) following a fusion MRI/ultrasound biopsy in April ‘22. He presented with an initial psa of 47 In February ‘22. His PSA was 31 three weeks later followed by a rise to 36 in April ‘22. He had four negative DRE’s by four different urologists. In March/April he underwent a 3T MRI (Pirads 4 lesion and 5 lesion confined to prostate), a negative bone scan and a negative CT scan. The biopsy showed low risk 3+3 Gleason 6 and intermediate favorable 3 + 4 Gleason 7 in 17/22 cores with low volume of pattern 4. The kicker is there was one single core at the base showing less than 3mm of Gleason 4+5. = 9. This Gleason 9 did not show on 3T MRI. His prostate was 101 cc, so it was suggested to have Robotic RP with lpnd. Surgeon said radiation would be difficult given prostate size. He contracted Covid just before May surgical date, so his surgeon elected to start him on three week Casodex followed by three month Lupron. Surgery in Sept revealed his prostate shrunk from 101 cc to 65 cc and there were ADT treatment effects notes (so no final pathology Gleason score). We were shocked to find there was bilateral Seminal Vesicle invasion though the previous MRI and CT scans did not show this. The surgical pathologist said the seminal vesicles appeared grossly unremarkable. The prostate was fully intact and appeared grossly unremarkable. PNI was present in the prostate but no other adverse features such as ECE, positive margins, or the 11 lymph nodes were affected. The adipose tissue was negative as well as the bladder neck. The nerves were spared. The surgeon at Yale Smilow Cancer Hospital was confident he got all the cancer and wants to wait three months to see the PSA. He does not want to use any further ADT at this time. He is Stage 3b and I am terrified that he should start with early Chemo, ADT and radiation when he is healed to be safe. Can anyone give me any suggestions or hope for him? We live in CT, so would be willing to travel to MSK for second opinions. I am terrified. I am scared to wait for three months.

Thank you Jack. I am wondering the same thing. Just before the surgery less than three weeks ago, his testosterone was less than 12, so maybe the surgeon feels he is still protected. He has a well regarded surgical oncologist at Yale, but if he is detectable in December, I want to consult with Memorial Sloan Kettering for their take.

Thank you Djin, His doctor had him start a three month course of Lupron preceded by three weeks of Casodex due to the fact that his surgery had to be postponed. He contracted Co-Vid three weeks prior to surgery that was scheduled for late May '22, and Yale would not operate per their protocol that it would be too risky for blood clots with recent CoVid. Therefore, he thought if he started a three month course of ADT, it would put a gate around the cancer and there would be no further advancement and maybe some regression prior to surgery in September. He said he anticipated scarring from the Lupron effects on the cancer in the prostate, so he wanted to wait until September to perform the surgery when the cancer was in the "sweet spot" as he calls it and beaten down. I am hoping that the Seminal Vesicle invasion was intraprostatic because no extraprostatic extension was noted. Since the vesicles looked normal on outer inspection, I am praying it was an early find, but am not sure. Thanks again for your advice.

The seminal vesicles lie outside and alongside the prostate. However, the seminal vesicles are removed along with the prostate, so it is not excluded that all one's cancer is also removed if is it confined there. Extraprostatic extension is a separate finding: it occurs when the cancer grows through the thin prostate capsule.

Seminal vesicle invasion can range from microscopic to total, and on one or both sides. However, once it is documented to any degree, it counts as an adverse finding and risk factor.

Djin

Post Edited (DjinTonic) : 10/7/2022 4:21:41 PM (GMT-7)

Thank you also Sr. Sailor. All the feedback is very welcomed!

It is unsettling for sure but a few things

1) Do you have any sense of his testosterone level? I was going to suggest a psa test at 6 weeks but just realize that if his T level is still low from his adt treatment his psa number would be affected and you would not be able to tell if you are undetectable because of adt or successful surgery. It will make you feel good though! If you get the psa test early also ask them to check his testosterone so you know.

2) assuming the surgery was not successful (there is a good chance it was!!) the next stop on the train is radiation with additional hormone therapy. chemo is often not in the cards unless there are some number of metastasis, many years from now. So you can take chemo off the things to worry about list.

3) heal. take the time to heal and appreciate life. Its been a *rough* 6 months for you guys. Enjoy Halloween Thanksgiving and Christmas.

4) You have done everything you could possibly do. You have taken a mighty swing at his cancer. Have faith in that.

5) When it is time ask for the ultrasensitive psa test. It has the ability to detect something even if it is less than 0.1.

Maxwellcatmom said...
Steve, Thank you so much. It was just what I needed to hear before I head to bed to reduce my anxiety. I am the researcher and worrier and my husband is not worried about a thing….he trusts his team at Yale, and feels confident he has years to enjoy. Thank you for your advice and opinions. Very glad I found this forum.

IMO you are both correct! Having a doctor/team of doctors you can trust is crucial, and the more trust you have in their knowledge, skill, and experience, the more confidence and weight you can give to their advice. It is also true that being well-informed helps you ask the questions you need to make good, informed decisions, put your mind at ease, and avoid treatment regret. You and your husband are a team.

A strong ace-in-the-hole we have with prostate cancer (especially after after surgery) is PSA, which becomes an exquisite metric for tracking the persistence/recurrence of prostate cancer. It, your husband's path report, the expertise of your medical team and any imaging they suggest, your research, any other consultations/second opinions you want, and your husband's decisions will all come together so you can plot the best course regarding treatment decisions.

Djin

Post Edited (DjinTonic) : 10/8/2022 6:23:14 AM (GMT-7)

Greetings catmom - I saw my Urologist at 3 weeks post-op (catheter out at 10 days) and again at 3 months after PSA test. At 3 weeks, we went over pathology and initiated Decipher testing and pathology 2nd opinion. His most basic advice was to focus all attention on healing up from surgery and we will worry about next steps after we get the additional results and the 3 month PSA result. It was undetectable then but we had the Decipher and 2nd opinions results back which were a mix of good and bad news and off to discuss with radiation oncologist and make some decisions.

That being said, your husband being on ADT suppresses PSA so an undetectable result will not be meaningful until the effects have cleared his system (testosterone is back up to reasonable levels). This basically means that the two of you can do nothing but worry until you get to that point which is not healthy when the all the focus should be on slowly getting him back to his pre-surgery shape. There is no reason to expect the worst at this point given the good news that existed in his pathology.

So in the much easier said than done category, try to focus on getting him to a good place physically and mentally and try to not focus on all of the "it could happen" stuff. Worry about the PSA results after they take his blood and not before. Sure sounds simple, right? Much tougher in reality but what you you should aim for. Hope he is doing well with his recovery.

Like my wife you do the research and the worrying. Your husband is going to a great facility. Not to be too kubaya, but don't ever underestimate your husband's positive attitude.