Tertiary 5 at the bladder neck.

[Cyclingrealtor]

Hey guys, looking for feedback on a specific pathology feature - tertiary 5 patterning.

How has your treatment/ management been at knocking this out or keeping things quiet?

September 2021 I was a PSA 16.2/ 4+3/ RARP/ svi/ pni/ epe/ 36 lymph nodes clear/ with tertiary 5 patterning at the bladder neck. I was <.1 for 8 months and then went .1 in April, and .3 seven weeks later and .4 another 6 weeks after that. PSMA PET showed 1 lymph node in the deep right pelvis positive. I have started ebrt and lupron 3 weeks ago.

Anyone with a similar pathology? 🙏🏼

Suggestions on treatment?

[KocoPr]

Sorry but i had to look up tertiary Gleason pattern 5 And I still don’t understand it, but here is an 8yr study published in 2019

Significance of tertiary Gleason pattern 5 in patients with Gleason score 7 after radical prostatectomy: a retrospective cohort study.

ncbi.nlm.nih.gov/pmc/articl...

[Optimistic49 in reply to KocoPr]

Thanks. My understanding is : the tertiary pattern is the 3rd most common pattern. It is reported only if it higher than your other 2 most common patterns. Given that a number 5 is greater than either his most common numbers of 4 or 3, it is reported as a 3rd pattern. Some studies have shown that it increases risk of BCR in pattern 4-3 and should potentially be treated as a Gleason 8. I have tertiary 5 on pathology report as well.

[Cactus297 in reply to Optimistic49]

Very good explanation of tertiary five thank you!my son is also tertiary five and he was diagnosed at 49 and he’s turning 51 in August. I think there are some similarities to his present condition and yours.

[Tall_Allen]

Hopefully the EBRT+Lupron for 2 years will clean it up. There is a trial now to see whether adding Zytiga to the Lupron will be beneficial.

[Cyclingrealtor in reply to Tall_Allen]

Do you happen to recall what hospital / COE is conducting the study?

[Tall_Allen in reply to Cyclingrealtor]

There is a contact list here. Sorry, I meant Erleada (apalutamide):

clinicaltrials.gov/ct2/show...

[Cactus297 in reply to Tall_Allen]

Just saw your post. My son is tertiary 5 ….psa 20 only 2 Months after robotic RP. He’s had IMRT and he’s taking generic Zytiga/prednisone and Lupron . First three months check up was .07 and on August 7 he goes in for his second 3 month PSA. But he’s changing providers from UCSD to Phoenix Mayo due to his job so I don’t know if that will affect the PSA results. But I will let you all know how he does after he gets the results from his PSA from the Mayo. I am concerned that the PSA test will be done by a different provider even though the Mayo is supposed to be good.

[Cyclingrealtor in reply to Cactus297]

How did your son discover the elevated psa? I know a few guys who have Kaiser in San Diego and it's a dangerous train wreck getting care there. So I am happy to see that your son is getting care at UCSD! The Mayo Clinic in AZ will be a great place for him to get PCa care!

Hang in there. It's a hurry up and wait process for sure.

Reach out if there's anything I can share my experience with. All the best!

[Cactus297 in reply to Cyclingrealtor]

Thanks so much for your reply. When diagnosed he was 3+3=6 and 3+4=7. He went to several SDIEGO specialists and they all recommended robotic RP with the same surgeon. We were optimistic that it might be a once and done. After the October 24 th surgery 2 months later my son went for his first PSA follow up and it was 20. Then a PSMA Pet Scan followed and it showed spread to the pelvic lymph node plus surgery results showed Tertiary 5. They put him on generic Zytiga/prednisone and Firmagon but he had a very bad Firmagon experience so they changed that to Lupron. He was also given 6 weeks of IMRT. So far so good. His 3 month checkup in March was PSA .07. Next PSA at Mayo August 7th. I’m a bit concerned because it’s a different testing facility. That could affect the PSA test results. Yes this really is a journey. I thought your journey has been quite similar too. I’m hoping they got all the cancer with the IMRT but they told him it was no longer stage 3 now stage 4 but with no Mets yet in March. Since it’s also tertiary 5 my hopes for a total IMRT cure are probably a pipe dream but will remain optimistic for now. This really is a test to test journey for all of us.

[Optimistic49]

I had some similar pathology, but struck out with salvage radiation/short course ADT. PSA now low but climbing (I’m off ADT at the moment, and PSA went up shortly after testosterone recovery). Now on list for 2nd PSMA-PET as no mets identified first time. I did early salvage at around PSA .14. I’m hoping to find out where it is before next step. As you know where yours is, hopefully you will slay the beast. Good luck

[Cyclingrealtor in reply to Optimistic49]

Sorry to hear about the bcr! My oncologist suggested 2 years of adt rather than one 6 month treatment. There are some trials out there adding a second immuno therapy with the Lupron/ Eligard.

Your treatment sounds more like a adjuvant radiation vs salvage. Who's your health care provider?

There was a study by a Stanford doc (??) that had a trial where they applied radiation to the whole pelvis rather than just the prostate bed while administering radiation for an adjuvant treatment. His study was based on the premise or findings that typically the PCa mets to the near by lymph nodes on recurrence. Looking at my surgery and pathology that's exactly what happened.

My treatment would be considered a salvage radiation treatment because I had bcr. The PSMA PET scan showed a deep right obturator lymph node (right side lymph node outside of the prostate bed). Here's the CRAZY thing I need to have a conversation with the radiation oncologist about - his notes state that extra radiation was applied to the "left" side that showed positive when the PET report CLEARLY states "right side" in three different areas. I need to have them pull the dosing report to see where the radiation was actually applied. Wrong side? Typo in his notes? 🤔😬

I had asked the other day about any future radiation and he stated that I could never have any more radiation to the pelvis.

Best wishes to you as you make your way this! 🙏🏼💙

[Optimistic49]

I’ll have to get my profile going as it gives a better picture. When I started the journey(first psa test ever is 36 in fall 2016), I've tried to weigh all these trade offs like all of us. Although I was high risk - early onset at 49, T3AN0M0, Gleason 4-3 tertiary 5, I chose surgery so that pathology would be more accurate. I had 1 dose Firmagon while waiting for surgery (spring 2017). Surgery successful - negative margins, low psa etc - but I didn’t want to go through additional impact of radiation right away so chose to wait with understanding we’d address at earliest concern if necessary. This worked for about 2 1/2 years and then steady rise in psa. I chose 0.1 as the marker to consider more treatment with understanding earlier the better. Did PSMA-PET just before radiation with nothing showing . I then did 33 radiation treatments - prostate bed and pelvis - and 2 3-mth shots of Zoladex. Worked well for about a year. ADT works well to keep my testosterone/psa down, but radiation wasn’t curative which was the goal (and I’m not an ADT side effect fan). Therefore now letting psa drift up so that PSMA -PET can pick up location (which may not be radiated area - not good as we did whole area). Then we’ll move to next set of fun (yes, likely more ADT..) . Location - Canada.

[Cactus297 in reply to Optimistic49]

I am hoping the IMRT was curative but with the Tertiary 5 factored in it probably won’t be. But am remaining optimistic until the next PSA test August 7th. Last one in March was .07 but this is such a sneaky disease. My son’s on ADT too. Your strategy sounds well thought out. I hope 🙏🏻🤞it goes well.

[Optimistic49 in reply to Cactus297]

Thanks for your note. I wish him well. Great for him to have you as support. Being on ADT is a huge challenge for me re side effects. The bad hot flashes during work can be a challenge like during client presentations. Weight gain has been a problem for me also, and I suggest he be proactive in nutrition and weight lifting. I keep telling myself it will only get harder if we don’t get the proper daily nutrition/exercise routines at the front end. I’m assuming I’ll be back on ADT this fall after my next PSMA-PET scan. My medical team told me at the front-end that with an initial high psa and tertiary 5 that it would be a grind. But they also said to be positive as there are a lot of tools in the toolbox for the battle.

[Cactus297]

My son doesn’t say much about side effects but he did mention hot flashes but it’s so hot in the desert we are all feeling it. He exercises regularly in SDiego but the weather is great there for outdoor exercise. Not sure what he’s doing since he arrived here. Since I am a mother not a SO or wife I try to be supportive but not intrusive. Your situations are pretty similar with so many different situations on here. I’m definitely still on a learning curve. I hope things go well for you too.🙏🏻🤞 My son I think sees me as support. The last thing I want is to be is a PITN! He has enough to deal with. But I need answers not just for him but for myself too. I don’t talk about it frequently with him, but the research and talking with all of you helps me too. Thank you.