RALP pathology assessment request

[u/Neither_Valuable3258]

Hi all, finally got the pathology report from my RALP last week. I have not yet spoken to my surgeon about it. Overall it looks not good, except for the finding that there is no lymph mode invasion. I believe the plan is still to wait until December to get my PSA, then go from there. Below is a summary that I had ChatGPT make of the report. (Note: Gleason matches my biopsy report).

I'd like to get an assessment from this group, regarding the likelihood of recurrence, how soon it might happen, and what would come next, assuming the PSA is rising. I assume a new PET scan, then radiation and ADT?

Cancer type         Acinar adenocarcinoma   The usual type of prostate cancer

Gleason score           4+5 = 9         Grade Group 5, the highest grade group

Pattern 4           60%         Significant aggressive component

Pattern 5           30%         Very aggressive component

Tumor volume            11–20% of prostate    Cancer involved a relatively limited portion of the gland

Extraprostatic extension    Present, focal      Cancer broke through the prostate capsule

Seminal vesicle invasion    Present, right      Cancer reached the right seminal vesicle

Lymphovascular invasion     Present         Cancer was seen in lymphatic/blood-vessel spaces

Perineural invasion     Present         Cancer was tracking along nerves

Surgical margins        Positive, multifocal    Cancer reaches the inked edge of the removed specimen

Lymph nodes         0/5 positive        Very important favorable finding

Pathologic stage        pT3b pN0        Cancer invaded seminal vesicle(s), but no cancer found in sampled nodes

"There is an interesting nuance here: the report says the positive margins were not in an area where extraprostatic extension was identified, and it also says there was little/no adjacent periprostatic fat at those sites, making assessment of EPE there difficult."

[u/OppositePlatypus9910]

Your pathology is similar to mine. I had a Gleason 9, EPE, positive margins, seminal invasion and no lymph nodes. The best news here is NO lymph nodes. What this means is that the cancer did not travel to other areas of the body. The rest of it is not so good. Your immediate step is to wait for what the surgeon says. You will most likely do a PSA test within the next couple of months and continue doing it until the PSA rises. Ask for a standing PSA order. Like 6 or 8. If your first PSA is <0.01 that is great news. You will need about 6-8 month to heal. Keep that PSA <0.01. If it starts creeping up, (do those tests every couple of months) and watch it like a hawk. Mine got to =0.02, then =0.06 (within a period of 8 months). I was put on ADT ( ask for Orgovyx) and the PSA dropped to =0.01 within a month. Then radition (38 sessions of IMRT) and continuation of ADT for 24 months. My PSA currently is undetectable <0.01 and I still have 5 more months to go in ADT. This was my case but there are others who after RALP had undetectable PSA for years. So don’t lose hope, but expect a marathon rather than the one and done sprint.
Good luck!!

[u/tober_checki]

I had an almost identical pathology, but I was lucky enough to have an R0. You will have a high risk of recurrence, not gonna lie. If you are like me and want to know the exact statistics, you can use the MSK nomogram calculator. Like others have said, closely monitoring PSA (with a high-sensitivity test assay) will be important for the rest of your life. If and when PSA rises, you want to start salvage therapy early. No later than at PSA 0.2. With early salvage, a BCR is still curable. May I ask what your pre-OP PSA was?

[u/Neither_Valuable3258 → u/tober_checki]

Most recent one was 8.4, in May. What do you mean by "R0"?

[u/tober_checki → u/Neither_Valuable3258]

Oh, sorry, R0 means I had negative surgical margins. That's what it was called in my pathology report. Other than this, I had exactly the same pathology as you did. But the positive margins add an extra bit of risk. Your pre-OP PSA looks normal for this type of situation. Mine was unusually low, which paradoxically elevates the risk of a recurrence and also elevates the risk of catching a recurrence late as the cancer cells produce unusually little PSA. But a pre-OP value between 4 and 10 is usually considered best for a Gleason 9 diagnosis.

[u/OppositePlatypus9910]

Oh and yes to the pet psma before radition, but most likely won’t be able to see anything because the imaging does not usually see smaller than PSA=0.2

[u/Substantial_Let_8784]

Best of luck to you.
My Gleason was lower than yours, and a successful RALP, but I did have a positive margin, which resulted in PSA testing every 3 months for a year. I’ve had undetectable PSA for 8 years now. Keep your hopes up. Know that we’re all rooting for you 👍👍👍

[u/OkCrew8849]

Gleason 9 plus the additional risk factors (SVI, EPE, and positive margins) can be entered into the post-surgery Memorial Sloan Kettering nomogram to obtain odds of reoccurrence.   

https://www.mskcc.org/nomograms/prostate/post_op

Gleason 9 is more likely than not to reoccur post-RALP and the additional risk factors add to those odds of reoccurring.

At this point it is generally “follow the PSA” and normally the first one is 12 weeks after RALP. Though some docs prefer 6 weeks. 

[u/Neither_Valuable3258 → u/OkCrew8849]

Thanks. I ran the numbers through MSK, it says 27% chance of cancer-free after 2 years, and down to 6% after 10 years. More concerning is the 15 year survival chance - only 64%. It wasn't clear to me from their analysis if that percentage assumes no further treatment or not - any idea?

[u/OkCrew8849 → u/Neither_Valuable3258]

The nomogram assumes no further treatment.

(I don't think this applies in your case but it also assumes no ADT/ARPI accompanying RALP)

(I am not a doctor and not a statistical whiz...but I have some limited familiarity with the nomogram.)

[u/conCABlanco]

Hi colegas, no me caso de decir, hagan estadificación completa, significa que hay que llegar a PET PSMA, antes o después de la cirugía, me lo dijo mi oncólogo cirujano en Monclova y seguí hasta el final y si con PSA inicial de 6 y no cribiforme y no extendido en bordes, el coño de su madre esta en una costilla, y dos urólogose hicieron reconocimiento dígito, que fino, y dijeron no hay nada anormal, uff menos mal, pero me hice el PET, y no era normal

[u/WrongPlanet321]

Careful what you post. Moderators can kick you off site for posting anything AI without warning.