I had a robotic assisted radical prostatectomy 3 weeks ago. No urinary control issues since the catheter was removed and ED doesn't seem like it's going to be an issue at this point either. I guess I'm one of the lucky ones in that respect, Unfortunately my final pathology showed my Gleason score to be 3+5=8 with extraprostatic extension (non-focal) along with perineal invasion. Lymph nodes and seminal vesicles were clear. My original biopsy showed Gleason 3+4=7 and was confirmed with a second opinion by a center of excellence. PSA 4.2. So, with that I have a few questions.
Should I get a second opinion on the final prostatectomy pathology to verify the pattern 5 isn't actually a pattern 4? If so, does Epstein do these?
Regardless of the pathology report, what are my options now? The surgeon said wait 3 months and see if my PSA is detectable. If not, then keep checking every 3 months and go from there. Is this a viable option?
If adjuvant radiation is in my future can they just treat the area of extraprostatic extension or will they radiate the whole area?
Should I get the new PSMA scan right away to see if the cancer that is left is visible?
Thanks in advance for any helpful information!
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Hiker64
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First things first. PSA test after 5 weeks not 3 months. With your pre-surgery 4.2 you could had it at 4 weeks but many will tell you 6 weeks without bringing into account the pre-surgery value. Post this and in absence of any nasty surprise, 5 monthly PSA tests to derive a pattern. Then you will be able to make a decision based on data and not personal preferences. In my country carpenders' wisdom has it: "Measure five times before cutting".
Read it again: "perineural" extension or "perineal" extension. HUGE difference between those two similar Greek terms. HUGE difference in clinical significance, too. Not unusual for the final specimen reading to be higher than the TRUS biopsy reading as noted by several in this forum. Before you worry yourself to death, you might discuss with your MO.
"Should I get a second opinion on the final prostatectomy pathology to verify the pattern 5 isn't actually a pattern 4? If so, does Epstein do these?" Usually unnecessary. Reading whole-mount pathology is a lot easier than trying to count cancer cells in small biopsy cores. Epstein does do it, though. You said 'perineal invasion" - it's very hard to know they got it all when cancer has invaded the muscle tissue at the apex.
" what are my options now? The surgeon said wait 3 months and see if my PSA is detectable. If not, then keep checking every 3 months and go from there. Is this a viable option?" There was just a recent study showing that adjuvant radiation is preferred to waiting for the PSA to rise in certain high risk pathology cases like yours:
While immediate radiation can undo the excellent continence and potency results you've had so far, it may be possible to delay radiation by about 7 months by starting on ADT immediately. This will give tissues more time to heal while curtailing any risk of spread in the interim.
"If adjuvant radiation is in my future can they just treat the area of extraprostatic extension or will they radiate the whole area?" They will radiate the entire prostate bed with a lower dose of radiation with a boost dose in the area of known infiltration. PC spreads microscopically throughout the area, and with pattern 5 the risk is higher.
"Should I get the new PSMA scan right away to see if the cancer that is left is visible? " No point to that. Even if it is macroscopic enough to show up, the PSMA radio-indicator they use is excreted via urine and is likely to mask the cancer in the area. The only possible benefit would be to show cancer in lymph nodes that were missed.
Thanks Tall_Allen. I looked again and it is perineural invasion which I guess means it was tracking along a nerve. Sounds like that's not a good thing?
Also my Decipher test was based upon biopsy samples which showed me at 0.79 (high risk), but the chances of metastasis was 2.6% at 5 years, 6.2% at 10 years, and a 15 year cancer related mortality risk of 8.6%. Would this change if they did the Decipher test again with the new prostatectomy pathology? It also showed my ADT response as a 4, Post-Op radiation response at 44, and Docetoxel sensitivity at 80. Does this mean ADT won't be that effective but Doxetoxel will be? Thanks again!
Perineural invasion on pathology is a common finding. So common, in fact, that it's often not reported. It adds nothing to your risk. But you are still GS 3+5 and stage T3a.
Your Decipher score is not worth re-doing. It means that you shouldn't use ADT as your sole therapy. Docetaxel seems to have little value pre-metastasis.
I always, and will continue to, seek second opinions. Telemed appointments are great, should you find a doctor who is far away from you, without having to get on a plane. I have done both in person and telemed several times, and my insurance has covered them all.
They generally radiate the whole prostate bed and sometimes include the pelvic lymph nodes depending on your case. My husband had a G 7 (3+4) with EPE and his RO recommended only the bed, BUT and that's a huge but, he had 37 nodes removed during his RP and all were negative. I'm sure that played into their decision not to do the whole pelvis.
How many nodes did your surgeon remove during your RP?
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post prostatectomy psa
Travel during RP recovery?
PSA Ultrasensitive 0.015 six months after prostatectomy
Detectible PSA two years after RP
When should we get first PSA test done post RP? 
