Prostate Cancer Network

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Likelihood of post-RP radiation?

Can anyone share their opinion as to my chances of escaping the need for post RP radiation treatments?

I’m most likely going to choose surgery as my treatment and it may take place as early as last week in September. I have my pre-operation consultation on September 10. I know I may not know whether I will be completely cured and whether or not I will need radiation post RP until after surgery. I have to admit that I’m hoping for any positive signs.

Here is my profile:

-59 years old; run 10-13 miles 3-4 days a week, half marathon once a year for the last 5 years, pescatarian diet,

-father diagnosed with PCa at 72 (G8) plus he had a bladder tumor he had to remove

-my Last PSA was 10.03

-TRUS biopsy 12 core, Nov 2017, 5 out of 12 cores with volume, all Gleason 6, some PNI in one core

-BPH, slow urination, and prostatitis symptoms for years before

-MRI-fusion confirmatory Biopsy results, June 2018 from 16 cores showed 4 higher grade cancers:

a 3+5 lesion

a 4+4

a 4+ 3

a 3+ 4

The above leads me to calculate from my report that the rest of this biopsy is Gleason 6 (4 cores) and Benign (7 cores).

Any thoughts given the above profile on the chances of escaping the need for radiation treatments post RP?

12 Replies

oldest • newest

Hidden

a year ago

I don't think anyone can predict the likelihood of you needing post-RP radiation treatment based on the information you have given.

Since you have apparently been advised that surgery is an option then it is safe to assume that there is a high possibility of a "cure" from the surgery. Presumably your MRI confirmed that the cancer has not metastasised because then surgery isn't usually advised.

SOME of your Gleason scores are, as you probably know, indicative of quite aggressive cancer, but that only means they will grow faster and spread faster if not dealt with. If treatment removes them ALL then they are no longer a danger.

The PNI (Perineural invasion) is a little worrying, but I believe this is often found and although this might increase the chances of some cancer cells "escaping" the gland, at least LOCALLY it isn't inevitable. it depends on how far cancer cells have spread along the nerve i.e. if they've outside the prostate capsule.

Does the MRI say if the cancer has spread out of the prostate but the spread is only LOCALLY?

The surgeon will remove all tissue that is apparently affected by the cancer, e.g. any local lymph nodes that are visibly affected and also some tissue that may not be apparently affected but which is "redundant" e.g. seminal vesicles.

If you have requested a "nerve sparing " procedure and the surgeon agrees to try this then they will probably remove less tissue than they would do otherwise.

After the surgery, the removed tissue is examined microscopically, particularly the edges or "margins" to see if cancer cells extend past the margins. If they have this is "positive margins". If they haven't negative margins. Negative margins means that the chances are, the surgeon has removed all the cancerous tissue.

The report should also say if the seminal vesicles and any lymph nodes are affected.

They will also recalculate the Gleason score.

Your chances of needing post op radiation.

Chances increased if MRI shows cancer cells have spread locally outside the prostate capsule - reduced if not

Chances increased if lymph tissue affected - reduced if not

Chances increased if nerve sparing - reduced if not.

Chances increased if positive margins (in fact advisable) - reduced if not.

What it ultimately depends on is your post op PSA levels. This may be tested 6 weeks, 3 months and 6 months post op. Your PSA should be small after 6 weeks and should be more or less zero within 3 to 6 months. In the UK it is undetectable in quantities any less than 0.01 nanograms per milliliter (ng/mL) This is considered as good as zero.

All being well, it should remain more or less zero permanently.

It should be monitored initially every 3 months then every 6 months, for about 5 years, then possibly yearly.

If it does not go down to VERY LOW levels within 6 months or goes to zero but later re-appears then it will be retested more often to see if it rising and how fast it is rising. If it reaches as high as 0.2 ng/mL then it is considered as "biochemical recurrence" and you WILL need "Salvage Radiation Therapy"

I'm afraid I can't quote any statistics on the number of men needing Salvage Radiation post RP, but I believe it is quite rare for there to be detectable PSA after RP.

Unfortunately, there is no exact way of predicting the outcome of your RP. There are tools called "nomograms" which attempt this based on statistical information. You can fill in a nomogram yourself. One can be found at

google.co.uk/url?sa=t&rct=j...

This particular nomogram will tell you your chances of staying recurrence free for up to 10 years and the chances of you surviving 15 years.

NOTE You need your POST OP Gleason score

My story PSA 6.2 ng/mL at diagnosis. MRI scan and bone scan both negative. Gleason score 3 + 4 = 7 at biopsy.

Laparoscopic nerve sparing prostatectomy carried out

Post op report Gleason 4 + 3 = 7, PNI, Cancer cells in close proximity to margins, total removal not guaranteed

PSA at 3, 6, and 9 months <0.01 PSA at 12 months 0.02 repeated after 6 weeks and 12 weeks 0.03 and 0.02. Thereafter repeated 6 monthly until present day (next due Nov 2018). Various up and down results up to a maximum of 0.1 ng/mL (a dubious result because of other factors). Remained at 0.07 for last 18 months.

MRI (because of back pain) 5 years post op showed osteoarthritic spine changes only.

Currently 6 1/2 years post op. No radiation treatment required.

My nomogram predicts I have a 96% chance of surviving 15 years post -op by which time I will be an "older" person, possibly with a well degenerated spine, much grumpier, hopefully still without stroke, heart attack, diabetes or the pancreatic cancer both my parents died from, still able to laugh at myself (other's do as well), but not able to do 20 push-ups. However, I've always been a physical wimp and I never have been able to do push-ups at all! Can't run 10 yards!

Good luck

3 likes

brilliant17

in reply to Hidden

a year ago

Tim2131,

Congratulations on your no radiation treatments after 6.5 years.

To your question, the MRI report stated that there was no extracapsular extension which I interpret as cancer has not metastasized. The MRI does not state that the cancer has spread out of the prostate. I also hope the no ECE statement means that if some cancer cells have left the gland at least locally they are still not outside the prostate.

Are both lymph nodes and seminal vesicles critical to avoiding ED? I assume seminal vesicles but not sure about lymph nodes.

So the more nerve sparing techniques are used, the more at risk one puts chances of full cancer removal?

I’m so appreciative of everyone on this network. I feel I am learning so much from everyone because we are all on the same journey or were at some point. What a great forum!

Hidden

in reply to brilliant17

a year ago

Hi. The NO ECE means as you say, that no cells have grown outside the prostate wall. Since cells would have to have left the prostate to get into lymphatic vessels then it is unlikely that this has happened. If they had done, some of them would have got stuck in lymph nodes, as these are a kind of filter. Lymphatic spread is one of the main ways in which the cancer metastasises.

The MRI should have picked up any lymph node involvement but this will be confirmed during surgery and by removing some lymph tissue which can be microscopically examined.

Cells can also spread through the blood vessels. This is a bit more complex as a) they have to get into blood vessels in the first place b) they have to travel through the circulatory system unimpeded and c) they would have to get out of the blood vessels somewhere else. So although it DOES happen, it is less likely that it spreads this way.

Unfortunately there is no 100% guarantee that this hasn’t already happened. In the UK it’s routine to also have a nuclear bone scan. A radioactive isotope is injected which has an affinity for bone. After a while the isotope gets absorbed into the skeleton. The whole body is then scanned for gamma radiation. If there are any bone metastases it shows up as “hot spots”. Perhaps your physician didn’t think this was necessary. Incidentally, this doesn’t hurt and you don’t glow in the dark.

NEITHER lymph nodes NOR seminal vesicles are critical to ED. Removal of either should not influence erectile function. The removal of seminal vesicles and the prostate gland itself means that sperm cannot get through and semen is not formed so you will be sterile. When you orgasm, there will be no semen ejaculated. Sperm will still be produced in the testes and theoretically, I guess they could be extracted if necessary but I’ve never heard of this being done and why would you want to at an age when you get prostate cancer?

What’s critical is the nerves one on either side. Traditionally, it used to be that surgeons removed the prostate and practically everything around it which included any nerves. Some didn’t even bother telling their patients that this would make them impotent. They assumed that men “of an age” weren’t interested in that sort of thing.

In nerve sparing surgery the surgeon “tries” to leave them intact. In some cases he or she may decide that it is too risky to leave one or both of them. The NO ECE means that there isn’t as much risk in your case. Unfortunately, when you see diagrams of these anatomical structures they all look clear and separate. Not so in reality, they may adhere to each other or simply obscure each other hence they “try”. Because of this sometimes they damage other structures e.g. so after the surgery they may ask if you’re having any problems with your bowels.

Even if the nerves are left intact, they may be traumatised and might not work properly for a while. Consequently, in the absence of erections, the erectile tissue in the penis starts to scar and the blood vessels start to occlude. If this happens then temporary ED can turn into permanent ED. This is physiological ED, no erections at all. This differs from psychological ED in which men still have erections, just not when they want them e.g. all men normally have erections when dreaming. So it’s important then to start “erectile rehabilitation£ as early as possible (as soon as the catheters out).

Unfortunately, it’s all a bit of a juggling act. Nothings certain and you have to make compromises between length of life and quality of life. I was always someone who wanted to know everything. I’m a problem solver. Since being diagnosed with PCa I’ve realised it might not be helpful to know some things or know them at a particular time. You can overcomplicate it and you can worry too much. Sometimes you have to take blind leaps. I’m pretty sure your doctors wouldn’t want you to take a leap over a cliff. It’s human to want to calculate risks, but sometimes it’s better to just to go for what you want (or avoid what you don’t want). I had NO ECE (T2), N0 (no lymph nodes) and M0 no metastases. I wanted to get rid of the prostate gland so I went for surgery (rather than radiation) and I didn’t want ED so I asked for nerve sparing. If nerve sparing wasn’t possible, I would have gone for radiation, I didn’t calculate risks at all.

Yes you want to avoid post prostatectomy radiation, but the point is, if the surgery does fail, you can then try salvage radiation. You can’t have it the other way round.

2 likes

AlanMeyerModerator

a year ago

I don't know if you'll need radiation or not. Tim has given some good info on indicators of when it might help, and Charles and Tim have given some good links to nomograms.

All I will try to add here is that, if you do have a rising PSA after surgery, radiation may not help but it's currently the only thing that has the possibility of converting a failed prostatectomy (failed in the sense of not removing all of the cancer) into a cure. If it turns out that your PSA is rising after the surgery and there is reason to believe that the cancer is still local I'd personally rather try radiation than not try it. In the worst case, it can leave you with terrible side effects and no cure. In the best case it can leave with easily manageable side effects and a cure. Where you fall between those cases depends largely on the competence and commitment of the radiation oncologist.

I had no surgery but both HDR brachytherapy and external beam radiotherapy, all done under ADT. That was 15 years ago and I'm still doing fine with no treatment since then. My biggest long term side effect was a gradual onset of impotence. But I'm getting older and I don't know how potent I'd be even without the radiation - probably better than I am but still not like I was in the good old days.

Best of luck.

Alan

2 likes

MichaelDD

a year ago

You are much like me 2 years ago (age 62 with the question of what option(s) I would take to fight this. I too took the choice of robotic removal. If I can tell you anything right now and you are an athlete start doing Kegel exercises NOW daily!!! I have done them for years. I went in to my surgery with a PSA 12, Gleason 8. After surgery I had my catheter for 7 days and it was removed. I have had TOTAL continence since. I believe that the Kegels were very instrumental in this. I have PSA called persistent. My PSA never zeroed. My first PSA after was .024. From there .042. What you need to know is that if you would need radiation whenever they do that it will "freeze" you at whatever continence you have at that time. Thankfully I was totally continent when I started radiation 3 months later. The minimum they wait to give radiation is 3 months. They want to be sure that you do have some continence and that they can go after the cancer aggressively in the shortest period of time. I came out of 39 sessions totally continent. Sadly my PSA went (& doubled ) to .080 after I finished. Now on to HT/chemo options. Good luck on your fight!!

1 like