Significance of tertiary Gleason pattern 5

Not completely similar, but, I had the surgery then biochemical recurrence. The way that I'd read that is that a the very end of the margin they had to test, they found cancer cells. I believe this would make it somewhat likely that they believe there may be more.

My margins were clear but had some invasion in blood vessels and nerve tissue. (none in lymph nodes, they took the closest one to test).

It's certainly a bit of a punch in the gut, but be positive. It's a marathon not a sprint. (unfortunately)

PSA is believed to have a 3 day half life. So if you have a reading shortly before the surgery, then the date (how many days after your surgery) you can do the math on what should your PSA be, or close to it. Mine went down as expected for no cancer then bounced back up. I was then referred to the RO for more treatment.

Unfortunately, there's not much to be done except watch and wait at this point. One PSA test really doesn't tell us much. I feel the best medicine is stay active and get on with living your life as best as you can while you wait for further tests down the road.

Best of Luck to you!

Many thanks for your reply. It is frustrating not being able to get more specific answers from my oncologist. Maybe he is trying to not give me the bad news but I would prefer knowing what I now can most likely expect.

I’ve wondered this as well. I had tertiary Gleason 5 2% also had some cribriform and pni tumor was 4+3. Clear margins, svs, and 13 nodes. 3month psa a couple of days ago < .1 hope it stays that way

Clear margins is a wonderful pathology report. My margins were not clear. Not sure how this can happen. My sense is I am in trouble but my oncologist will not admit it or give me a sense of next steps. Anyone else facing this dilemma?

I don't know if you have looked at the gleason score patterns https://koelis.com/what-is-the-gleason-score/
Your dominant patterns are 4/3. They found some cells in pattern 5, the more aggressive pattern. Biological recurrence is more likely with pattern 5. You'll be watching the PSA in case you need additional treatment.
May you never have recurrence.

Thank you. Yes I will monitor my PSA every three months.

Thanks also for the well wishes.

tstump12:
RP Aug 22; clean margins, lymph nodes and seminal vesicules.
But nonfocal EPE and Gleason score 9 foretold 1st postop PSA .19.
Referred to Radiation Oncology for evaluation for salvage radiation with ADT.
See SPPORT trial.
Completed treatment May/June '23; 6 mos post PSA < .02.
My Gleason score together with EPE foretold biochemical recurrence (BCR) and the need for additional treatment.
Hopefully your PSA will remain < .1 forever.

@tstump12

My path report showed 4+3 with no mention of Gleason 5 cells. Lymph nodes were negative. There was an area where the margins were not clear. But, the surgeon said he felt the tissue was "sticky" (whatever that means) there, and he took a little extra tissue from the sidewall in that same area where the prostate had been removed. All of that extra prostatic tissue was negative. I also had seminal vessel invasion. My 6 week, 3 & 6 month PSA were all less than 0.02 (I'm having my 9 month PSA next week.)

I did a little research and found several studies which predicted a lifetime risk of biochemical recurrence of 10-15% in my particular situation. The problem with such predictions is, for any individual, the end result is either 0 or 100%. And there is no way to know in advance which of those buckets you will fall into. As they say in betting circles, "That's why they play the game!" Most doctors know better than to say, "This is what will happen to you." Rather, they prefer to say, "here is what we will do to follow you". It's usually an algorithm which, in our case, starts with the PSA. Since there are endless permutations of how the PSA might evolve, again, a doctor will not tell you the full course of what might happen if your PSA starts to rise. There are so many "it depends" branching possibilities that it ends up being both confusing and scary.

So we are left not knowing what the future will hold for us as individuals. In that uncertainty, we need a physician who understands our fear and concern, and can provide assurance, that, no matter what the course ends up being, there is a plausible route through the diagnostic path to a treatment plan. It sounds like you are not yet getting that from your doctor. and that can be frustrating.

For me, I have a low-level anxiety that, someday my PSA might start rising. I also have a confidence that my medical team (I'm with Kaiser) has a lot of experience with many prostate cancer patients, and will provide whatever future evaluation indicates I need.

The primary score for becoming an oncologist is not patient communication. And then no one else wants to venture in where the MD does not. However, I'm a little confused because normally a urologist/surgeon does the operation, then refers you to an oncologist if needed for followup. Perhaps your experience was different. The labels are rather arbitrary as each MD has specific experience. My urologist has a specialty in prostate cancer, but his main expertise is robotic laproscopic surgery. I assume though if I need radiation I'll be referred to a "radioactive oncologist." Of course, that person wouldn't run the machines or pour the cocktails, just write the orders.
Anyway, as others have said and you already knew, while your report was not good, it was also not definitive. "Extraprostatic extension cannot be ruled out." Even if they thought it could, you could still have it, but your presentation is of concern. (MD code for "bad news.")
In my experience, oncologists are among the most optimistic, hopeful people on the planet. I guess you have to be to choose a career where all your clients are dying faster than usual and all your treatments are more likely to cause delay in death than outright cure.

@tstump12, that's not a great feeling to think your oncologist isn't being straight with you for fear of sharing bad news. I would want the bare truth too so that I know what I'm dealing with and can mentally prepare. As for next steps, I make sure I never leave an appointment without my being clear on next steps - clear to me. Sometimes the next steps are clear to the doctor, but not necessarily to me. So I repeat back what I understand next steps to be. That's gives the doc the opportunity to confirm I got it right or to correct my understanding, without being challenging.

Have you told him your preference and that you want clear and open communication, no matter the news?