Perineural invasion after RP: next steps?

[tallguy2]

A friend of mine has Gleason 7 PCa. He chose to have the RP. During a follow-up consultation he was informed that there were no positive margins, and there was no lymph node or seminal vesicle involvement. The report he was handed noted that he was positive for perineural invasion. He didn't catch this until he got home and read the report, and his doctor said nothing.

Q: I am correct that the next likely step for my friend is radiation therapy?

[Steve507]

I dont know anything about perinueral invasion. How severe is the invasion? Do they grade or measure it like length of margin or ... ? Please keep us updated

Hang in there!

[Hidden]

Perineural invasion (PNI) is a quite common finding of biopsies and RP pathology reports.

I am not sure whether your friend had RP or he intended to have one before learning about PNI. In the former case (RP done) his next treatment i.e. RT will be determined by tracking his post RP PSA.

[tallguy2 in reply to Hidden]

He had the RP and learned of the PNI post-surgery.

If his PSA post-RP is undetectable would you say no to RT? Thanks.

[garyi in reply to tallguy2]

PNI alone is not cause for SRT. Do watch post surgery PSA scores.

[Hidden in reply to tallguy2]

Definitely YES! Older practices recommended PSA > 0.2 for salvage RT.

Recently, this milestone has been cut short to 0.1.

There are over-treatment advocates that preach for adjuvant RT supposedly for "better" long term outcome (highly debatable issue). But even they, recommend it for high risk patients. With GS = 7 and nothing else, except PNI, your friend doesn't fall into this category.

It would be interesting to find anyone that had a radical prostatectomy WITHOUT PNI detected.

[Gemlin_ in reply to Hidden]

Studies report that at least 60 - 80 % of all RP patients have perineural invasion.

[tallguy2 in reply to Gemlin_]

I might try to find my post RP report from 2012. I don’t recall seeing that term.

[leach234 in reply to Hidden]

Plenty of people have RP without PNI. I had no PNI. There is inconclusive evidence whether PNI can increase recurrence. Some studies say up to 25% greater chance of recurrence.

[Ahk1 in reply to leach234]

I had RP with PNI and did SRT and it failed

[Tall_Allen]

No. PNI is frequently observed on pathology and is not a risk factor. Only his PSA will dictate whether SRT is needed.

[tallguy2 in reply to Tall_Allen]

Thank you.

[tallguy2]

Thanks to all who responded so quickly!

[Hidden]

I’m sorry about your friend. But this all too common. Next rt.. if PSA jumps .. good luck to him. Good he has you to tell him the truths of pc .✌️

[j-o-h-n]

Doctor Google:

Evidence of perineural invasion on prostate biopsy specimen and survival after radical prostatectomy.

DeLancey JO1, Wood DP Jr, He C, Montgomery JS, Weizer AZ, Miller DC, Jacobs BL, Montie JE, Hollenbeck BK, Skolarus TA.

Author information

Abstract

OBJECTIVE:

To better understand relationships between perineural invasion (PNI) and radical prostatectomy outcomes, we examined whether PNI was independently associated with adverse pathologic features and worse survival outcomes after radical prostatectomy.

METHODS:

PNI is a routinely reported pathologic parameter for prostate biopsy specimens. We identified 3226 patients undergoing radical prostatectomy for clinically localized prostate cancer at our institution between 1994 and 2010. We used multivariable logistic regression models to examine whether PNI was independently associated with extraprostatic extension, seminal vesicle invasion, and surgical margin status. We used Kaplan-Meier methods and the log-rank test to assess disease-free, prostate cancer-specific, and overall survival according to PNI status. Cox proportional hazards modeling was used to evaluate relationships between PNI and survival outcomes.

RESULTS:

PNI was identified in the prostate biopsy specimen in 20% of patients who underwent radical prostatectomy. Patients with PNI were more likely to have adverse pathologic features, including extraprostatic extension, seminal vesicle invasion, and positive surgical margins. Patients with PNI had shorter disease-free, cancer-specific, and overall survival (all log-rank P <.001). After adjustment for adverse pathologic features at radical prostatectomy, PNI was independently associated with disease-free survival (adjusted hazard ratio, 1.45; 95% confidence interval, 1.09-1.92) and overall survival (hazard ratio, 1.57; 95% confidence interval, 1.13-2.18).

CONCLUSION:

PNI was independently associated with adverse pathologic features and worse survival outcomes after radical prostatectomy. For these reasons, PNI on prostate biopsy specimens should be considered in prostate cancer treatment decision making and clinical care.

Copyright © 2013 Elsevier Inc. All rights reserved.

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 05/04/2020 7:48 PM DST

[tallguy2 in reply to j-o-h-n]

Thanks for posting this.

[Fanger1]

Hi Tallguy,

I'm Gleason 7 with PNI with a positive surgical margin. My doctors are following me with the standard Biomarkers and CTCs. It may be beneficial to advise your friend to ask for this as well. I'm using Biocept CTC testing.

[dadzone43]

Maybe yes; maybe no. For unknown reasons, the PCa cells like to get into the nerves. Mine did. I had RP and no RT and at 18 months, no elevation of PSA. My surgeon believes (or at least said) that the electrocautery used to remove the gland and the nerves kills any PCa cells along the margins and in the nerves. I do not know if this is true, but it IS a nice thing to believe in.