Had my follow-up exam with my urologist today, a week after my prostatectomy. Had the catheter removed. Then we went over the pathology report. I got good news and I got bad news.
•The good news: Gleason downgraded to 6 (3+3), no seminal vesicle invasion, no lymph-vascular invasion.
•The bad news: Extraprostatic Extension / Perineural invasion (surgical margins) present
Here is the text of the pathology report:
A. Prostate, radical prostatectomy (44 grams):
Bilateral well-differentiated prostatic adenocarcinoma, predominantly right lobe with a small amount in the left lobe; involving about 20% of the total gland; Gleason score 6/10 (3+3); showing perineural invasion , but no definite lymphovascular invasion; showing focal extraprostatic extension; showing wide involvement of the posterior surface of the right lobe; no evidence of seminal vesicle involvement.
B. Preprostatic tissue, excisional biopsy:
Adipose tissue with no evidence of tumor or lymph nodes.
C. Right pelvic lymph node, excisional biopsy:
One lymph node showing no evidence of mestastic tumor (0/1).
D. Left pelvic lymph node, excisional biopsy:
Two lymph nodes showing no evidence of mestastic tumor (0/2).
•Pathologic staging: pT2cpN0
•Specimen: Prostate and seminal vesicles (44 gm)
•Procedure: Radical prostatectomy and lymphadenectomy
•Prostate size: 3.2 x 3.5 x 3.0 cm
•Lymph node sampling: Bilateral pelvic nodes negative (R 0/1, L 0/2)
•Histologic Type: Adenocarcinoma
•Histologic Grade: Well differentiated
•Primary Pattern: 3
•Secondary Pattern: 3
•Teritary Pattern: N/A
•Total Gleason Score: 6
•Tumor Quantitation: Bilateral, approximately 20% of total gland
•Extraprostatic Extension: Focally present
•Seminal Vesicle Invasion: Not identified
•Margins: Right posterior surface, rest of margins clear
•Lymph-Vascular Invasion: No identified
•Comments: EPE is difficult to judge because tumor extends to the outer surface of the specimen. The right side of the prostate shows infiltrating small to medium sized glands, extending to the posterior surface of the right lobe and focally appearing to extend beyond the prostatic capsule. There is local slight involvement of the left side. Preprostatic tissue and lymph nodes are free of tumor.
Today's meeting with the doc seems more scary to me than the day I was diagnosed. I feel like the cards are stacked against me. My doctor said that a PSA test 6 weeks from now will drive what steps we take next, whether that be active survellience of my PSA or if we proceed right into radiation. He suggested that with radiation, the odds are good I'll be able to beat this. That may be so, but right now my wife and I are in shock and finding this hard to handle.
There may be reason for some concern, but certainly not for panic. You have Gleason 6 cancer, after all. It's been removed but there's a positive margin. Gleason 6 cancer isn't known for becoming wildly aggressive and spreading. It is generally an indolent cancer. The fact that you still have a tiny strip of prostate remaining from the positive margin shouldn't be a cause for warning lights to flash uncontrollably. First, only 50% of positive margins actually are viable; the other 50% die from lack of blood and from being sliced in surgery. Even if it were viable, it is still Gleason6, which many would have left alone without surgery.
Even the extracapsular extension doesn't sound very serious. It just seems to have grown through the capsule, without doing much of anything. I think your urologist is over-reacting. You should go get a second opinion. I bet a medical oncologist would prefer watchful waiting. And he/she wouldn't jump at the first rise in PSA, because Gleason6 cancer just doesn't develop very fast. There would be plenty of time to decide on treatment if the PSA started rising unexpectedly fast.
Obviously you shouldn't take my amateur opinion all that seriously, but do get a second opinion. And as I said to rcroller, now that your urologist has removed the plumbing, you'd be better off seeing a medical or other oncologist who knows much more about any treatment you would consider after this point.
Hey John! Fancy seeing you over on this board too. I already responded to your post over on HW so won't repeat myself (much) but while sure, it could have been better, it isn't all that bad either. Lots of good stuff too...If you run your numbers through the Sloan-Kettering calculator for chance of recurrence, I think you may feel somewhat better (I know I did). The odds are much in your favor! Take care and Deep breath...
focus on healing! Hang in there...it will get better.
You've had some great responses from Bob and Tom as I read this thread, and I hope you and your wife are encouraged by them.
Tom's detailed response is right on target as I see it.
I will add two important suggestions. First, for a case like yours, ultrasensitive PSA tests are most valuable. The best versions give reliable results to <0.01 in a practical clinical/lab setting (even lower but with unknown meaning with special procedures). That is of great value in giving the patient and doctor far earlier awareness of a recurrence, allowing earlier salvage and/or hormonal therapy intervention, but also providing powerful motivation to the patient and family to implement those lifestyle tactics that are all that many of us need. That's my second point. For many patients, the ultrasensitive tests give early peace-of-mind by showing that the patient has extremely good odds of not facing a recurrence.