Update after RALP ---- Need advice

[FMOH_N]

Dx in May 23:

Biopsy results:

PSA day before biopsy: 6.2

3 out of 10 confirmed cancer in peripheral zone right side GS: 2 x 3+3 and 1 x 3+4 (GP4 - 40%) .

MRI in April 23 detected malignity tumor of size 1.2 cm, PI-RADS 4. No sign on pelvis area and neighboring lymph nodes. Clinical stage: T2b.

RALP in June 23:

Histology results:

tumor location & size: Right dorsal lateral / 14 x 8 mm

tumor type: Acinar adenocarcinoma

number of tumors: 1

presence of Intraductal carsinoma: positive

Gleason score 4+3 (70% pattern 4 with cribriform)

Grade Group: upgraded from 2 to 3

EPE: negative, SV: negative, microscopic bladder neck and lymphovascular infiltration: negative, PNI: negative, surgical margins: negative, pT and pN classification: pT2 - pNx

So after RALP the GS is upgraded to 4+3. In addition the pattern 4 is now found to be of type cribriform and Intraductive carcinoma presence. (high aggressive and adverse outcomes, metastases and survival)

As I understand the treatment options for 3+4 and 4+3 are not identical and different.

So the question now is what to do? Do I need SRT, HT and/or ADT now? Maybe considering Chemo?

PSA <0.1 (6 weeks post RALP).

[Justfor_]

You only need to close monitor your PSA (preferably monthly). Shed out of your mind sRT, HT, ADT and anything related to BCR, until you have got tangible evidence that a BCR is brewing. The sole judge of the latter will be your PSA time series. PSA lab precision of min 2 decimal places, better 3 decimal places. Check if your doc is ok with prescribing Avodart. There is a number of published papers claiming that post RP Avodart prolongs the time to BCR.

[Tall_Allen]

That is a great report! T2 means your cancer was contained within the prostate that was removed.

You do nothing. 3 months after your prostatectomy, you will have a PSA test. (IDK why you had a PSA test today - it is too soon after your prostatectomy and tells you nothing. You have to wait 3 months to let all the PSA released by your prostatectomy to get filtered out.) If your PSA is undetectable at 3 months, you will have another PSA test 3 months after that, etc. If your PSA continues to be undetectable, you can switch to a 6-month or annual schedule.

[FMOH_N]

Many thanks Justfor and T_A. However, unfortunately IDC and cribriform architecture is bad news.

nature.com/articles/s41391-...

Conclusion

The presence of CP is associated with adverse pathology at radical prostatectomy and worse biochemical recurrence and cancer specific mortality. These results highlight the importance of a better pathologic report of CP to advise clinician for a strict follow-up in PCa patients.

[allie2020]

Like TA, I think your report is very good. I had my RALP in 2018 and was also T2. My Urologist told me the most important thing in the report is negative margins. I am no expert on cribriform; I've read many different things regarding its significance or lack thereof. I think you should strongly respect TA's opinion on that. I had my first ultrasensitive PSA test at the 13 week mark ,then every 3 months the first year. Please be sure to get the ultrasensitive test and it's best to use the same lab.

[Tall_Allen]

You are just catastrophizing. That link doesn't say that " cribriform architecture is bad news." You are making that up, and causing your own anxiety. It says that cribriform is riskier than Grade Group 2 (Gleason 3+4). So what?

[FMOH_N in reply to Tall_Allen]

pubmed.ncbi.nlm.nih.gov/269...

Abstract

Invasive cribriform and intraductal carcinoma in radical prostatectomy specimens have been associated with an adverse clinical outcome. Our objective was to determine the prognostic value of invasive cribriform and intraductal carcinoma in pre-treatment biopsies on time to disease-specific death. We pathologically revised the diagnostic biopsies of 1031 patients from the first screening round of the European Randomized Study of Screening for Prostate Cancer (1993-2000). Ninety percent of all patients (n=923) had received active treatment, whereas 10% (n=108) had been followed by watchful waiting. The median follow-up was 13 years. Patients who either had invasive cribriform growth pattern or intraductal carcinoma were categorized as CR/IDC+. The outcome was disease-specific survival. Relationships with outcome were analyzed using multivariable Cox regression and log-rank analysis. In total, 486 patients had Gleason score 6 (47%) and 545 had ≥7 (53%).

The 15-year disease-specific-survival probabilities were 99% in Gleason score 6 (n=486), 94% in CR/IDC- Gleason score ≥7 (n=356) and 67% in CR/IDC+ Gleason score ≥7 (n=189). CR/IDC- Gleason score 3+4=7 patients did not have statistically different survival probabilities from those with Gleason score 6 (P=0.30), while CR/IDC+ Gleason score 3+4=7 patients did (P<0.001). In multivariable analysis, CR/IDC+ status was independently associated with a poorer disease-specific survival (HR 2.6, 95% CI 1.4-4.8, P=0.002). We conclude that CR/IDC+ status in prostate cancer biopsies is associated with a worse disease-specific survival.

Our findings indicate that men with biopsy CR/IDC- Gleason score 3+4=7 prostate cancer could be candidates for active surveillance, as these patients have similar survival probabilities to those with Gleason score 6.

[Tall_Allen in reply to FMOH_N]

Of course, yours was whole mount detection, not biopsy, but I'm glad to see you found evidence of excellent outcomes with cribriform.

[FMOH_N]

Good reading stuff

EAU guidelines:

uroweb.org/guidelines/prost...

[FMOH_N]

pdf.sciencedirectassets.com...