Feb
01

Gleason Grade 7 or Above: Why You Should Consider Open Surgery

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I want to pass on some information that newly diagnosed men absolutely should consider. It is from the excellent blog “Palpable Prostate” by A. Black.  The gist of this is that for intermediate- and higher-grade PC pts (GL 7+, PSA 10+), *open* surgery for PC is considered preferable to laparascopic (which includes robotic) surgery by a number of notable surgeons. One reason is that it allows for more extensive dissection of the lymph nodes, which is very important in this situation.

I am NOT saying that if you are in an intermediate or high-risk category you should not have minimally invasive RP.  What I am strongly suggesting is that you consult at least one open (traditional) surgeon to get a different point of view.  Do some research and find the most qualified doctor in your area.  Don’t settle for just anybody.

Dr. Alan Partin (of the famous “Partin Tables”), head of Urology at Johns Hopkins (top-rated urology faculty and top-ranked hospital in US by usnews.com), will not do a laparascopic RP on any patient with a Gleason grade over 7. This is also what I was told by Dr. Bertrand Guilloneau when I called about making an appointmentt for my husband a few years ago. Dr. Guilloneau pioneered the use of laparoscopic RP in France and was practicing it long before it was approved in the U.S.   He is also head of minimally invasive PC surgery at Sloan-Kettering, the #2-ranked cancer hospital in the US . (I understand that Dr. G. has since changed the rules, but I’m not sure why.)

The website I referred to, Palpable Prostate, has a 4-part survey of the relative merits ot the different kinds of PC surgery. http://palpable-prostate.blogspot.com/2007/03/rp-vs-lrp-vs-rlrp-part-1-open-surgery.html. Then there is a wrap-up of “what surgeons and others say”. The information here is comprehensive and well-sourced, with links to all cited references. Here is a pertinent excerpt of doctors’ opinions:

Dr. Kevin Slawin of Baylor College of Medicine:

“Dr. Slawin recommends that [patients with] Gleason 6 and less extensive Gleason 7 [3 + 4] can have laparascopic surgery, while patients with more extensive Gleason 7 [4+3] disease and Gleason 8-10 patients have open surgery and are most effectively treated when a careful, extended lymph node dissection, that includes the removal of all lymph nodes situated in the iliac, hypogastric, and obturator regions, is performed as part of the prostatectomy procedure. This type of lymph node dissection can only be best performed using an open, rather than robotic-assisted, approach.”

“Patients with larger Gleason 7 – 10 tumors, situated primarily at the base of the prostate, who have a high risk of seminal vesicle invasion, can achieve a lower positive margin rate and higher cure rates than those with similar tumors treated with standard techniques, either open or robotic, when treated with “en bloc” resection of the prostate, SVs and bladder neck.”

David F. Penson 

“An Evidence-Based Analysis (Feb 7, 2007) concludes that for low risk patients (all of: GS 6, PSA < 10, cT1 or cT2a) either open or robotic is reasonable, but for high risk patients (any one of: GS 8 or higher, PSA > 10, cT2b or higher) open surgery is preferred. For intermediate risk patients (GS 7) the proper approach is unclear.”

BTW, the results achieved of by minimally invasive surgeons (such as short recovery time), can often be equalled by an experienced open surgeon. Also, there is no evidence that the rate of ED is lower in patients who’ve had laparascopic PC surgery.   Finally, I believe there are fewer urinary problems with open surgerey.

In any case, read the information for yourself. Always remember that the most important thing in choosing a treatment is saving your life, i.e., *cancer control*.

Comments

  1. Larry says:

    I was diagnosed with prostate cancer in Oct 07/ Had surgery 12/26/07. Margins were good.Surgeon removed 12 Lymph Nodes which showed no cancer. My Gleason score pre surgery was 8. My PSA never breached 3. Post surgery PSA was not detectable (March 08). July 08 PSA elevated to .5. I waited until Feb 09 to begin radiation when PSA went to 1.6. Post radiation PSA (Jume 09) elevasted to 3.4. I am now T4 M2. My point is DONT WAIT for your PSA to get over 4.

  2. Shahrokh Mafi says:

    Is not it better for a patient who is diagnosed with Gleason Grade 6 of prostate cancer to remove the whole prostate gland? Is it possible to do so medically? Please advise me immediately. Thank you very much.

  3. Leah says:

    First, keep in mind that I am not a doctor. Second, I am not sure I understand your question. Can you tell me more about your stats e.g., PSA, stage, Gleason score, etc. As a general statement I can tell you that it is not always advisable to remove the prostate once a diagnosis of prostate cancer has been received. Many men are now being managed by “active surveillance” or watchful waiting, as it used to be called. They are given periodic PSA tests and biopsies to monitor the cancer. If the cancer progresses, active treatment such as surgery or radiation is instituted. The National Comprehensive Cancer Network, which issues guidelines for doctors, recommends active surveillance as the sole option for men who fit their definition of low-grade cancer (do a search on this blog on nccn for my latest article on this subject). You can find out more at nccn.org.

    Leah

  4. Karyn says:

    Hi Leah,

    First, thank you for this blog.

    Second – realizing fully that you are not a physician, I’m wondering what your thoughts are on a 57 y.o. male with a Gleason of 7 (3+4), a PSA of 10 (elevated to 10.1 in 8 weeks), and “T2″ stage prostate cancer. We are driving ourselves crazy with the options and relative merits and drawbacks of each, which second line of offense might be appropriate if the first technique doesn’t get the job done, and so forth.

    Any insight you have would be greatly appreciated.

    Thanks – K

  5. Leah says:

    Speaking as a non-physician, it seems to me that surgery is best viable option in your situation (that depends on whether the PC has escaped prostate, in which case surgery may not be beneficial. That leaves salvage radiation as an option later on, if necessary. Choosing radiation as primary treatment does not give you good follow-up options (e.g., salvage surgery) if the cancer returns. I don’t think active surveillance would be an option because your husband’s numbers suggest an intermediate grade cancer which, although highly treatable, should be actively treated.

    It is important to find the most competent surgeon available, in a hospital that is a center of excellence in cancer treatment (usnews.com has rankings). The experience of the surgeon is most important — don’t focus on the technique.

    My husband had practically the same numbers as your husband a few years ago and he chose surgery. We have not regretted our decision.

    Don’t be discouraged — you can have a life after prostate cancer surgery.

    Good luck,
    Leah

  6. Jack says:

    I am 60. Was referred to urologist because of 3.3 PSA. After 6 months, Urologist ordered needle biopsy. Results 6 of 16 cores (about 37%) effected with cancer. All are 3+3 except for 1 instance of 3 + 4 which is 90% 3; 10% 4. Also, PSA has dropped to 2.5

    My question is: am I a candidate for watchful waiting. I understand the Hopkins lit draws a hard and fast line on 3 + 4. On the other hand, there doesn’t seem to be evidence of fast-growth. Aureon test was favorable. Just had an MRI. I can have another PSA at the end of March. Mainly, I don’t want the urinary and sexual side effects. The doctor appears to be predicting full recovery. But am I really at risk if I hold off for a while. Also, is there anything non-invasive that is getting good results?

  7. Jessica says:

    My husband, at age 53 had PSA ~6 for a few years…had 12 needle biopsies, came back neg for cancer but had BPH, decided to do TURP to help pee better. TURP found cancer in about 1/5 of the sample, gleason 3+4…thoughts?

  8. Leah says:

    Dear Jessica,

    I’m sorry I did not respond sooner. I am giving the blog a rest for now because my hands hurt from spending so much time on the computer over the last five years. Better late than never — why don’t you update me on your situation?

    Usually I would say that a gleason grade 7 tumor should be treated aggressively, but now some docs are using active surveillance to treat men with the “good” gleason 7, i.e., 3+4 rather thanr 4+3. A lot of other factors have to be taken into account. I always advise not rushing into any treatment.

    All the best.

  9. John says:

    I have recently been diagnosed with prostate cancer gleason 7 i.e 3+4. PSA 7.4.I had two tumors out of 12 tissues which were sampled by needle biopsy performed by my urologist.
    Next step for me is to determine which method of treatment is best for my current condition. Undergoing whole body bone scan and pelvic MRI with and without gadolinium to put a better handle on the extent of the disease. Initial diagnosis is that it is contained to these two tumors in the prostate gland.
    Any rule of thumb for treatment method??

    John

  10. JIM K says:

    Recently diagnosed with prostate cancer PSA 3.8 GLEASON 4+5=9 in four of seven, right side benign. 54 years old good health no external knots or lumps just a color difference to the left side of my prostate biopsy came back left side adenocarcinoma 25% of needle some back pain schduled next week for bone scan and mri Doctor has labled me as high risk, plan on going to MD Anderson in Houston any thoughs.

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