Before we can determine the best course of treatment for your prostate cancer, it’s important that we work to identify what your risk group is. You may be asking yourself, “what is a risk group?” This is actually very important information to know.
Basically, your risk group is how we categorize the severity of your cancer so that we can determine how aggressive your treatment should be. Prostate cancer risk groups are categorized by low, moderate, and high.
Low Risk: Cancer is located only in the prostate, and the PSA is <10 and grade group 1 (Gleason 6). This group also has a subcategory of “slow-growing” or “very low risk.”
Moderate Risk: Cancer is located only in the prostate; the PSA is between 10 and 20, or grade group 2 or 3 (Gleason 7). This group can be further categorized by “favorable” or “unfavorable” based on other factors about your particular cancer.
High Risk: Cancer has spread to outside of the prostate, the PSA >20, or grade group 4 or 5 (Gleason 8 to 10).
These risk categories are used in conjunction with other information such as lymph node involvement and other factors to help determine the best treatment path.
Prostate cancer goes through three basic steps in growth.
The first step is a growth inside the prostate gland. For a long period of time, prostate cancer grows only inside the prostate and is contained by the capsule that surrounds the prostate. Think of a shell around an egg.
Eventually, the second step occurs – prostate cancer cell leakage through the capsule so that cancer grows next to but outside the prostate, which is officially called microscopic capsule penetration.
Now think of a hole in an eggshell with the yolk leaking out. If the growth outside the prostate is large enough, it can be felt on prostate examination (the DRE), which would make the prostate cancer a stage T3, but this is very uncommon. Almost all capsule penetration cancer is microscopic. If left alone, the third step will eventually occur.
Step 3 is the spread of prostate cancer (metastasis) beyond the prostate area to lymph nodes, bones, lungs, or any other place in a man’s body. Depending upon the treatment method, prostate cancer can still be cured in Step 1 or Step 2. With rare exceptions, prostate cancer is not curable in Step 3.
Cancer cell capsule penetration can occur in four basic ways. The first way is through the development of cancer adjacent to the capsule, with the cancer simply destroying the capsule (eating a hole in the capsule) and leaking out. Again, think of egg yolk leaking through a hole in the eggshell. A second way is through perineural invasion, which means cancer cells travel along branches of the sex nerve and “tunnel” through the capsule to escape the prostate. The third method of microscopic capsule penetration can occur when cancer cells are located at the bottom (apex) of the prostate because there is no prostate capsule in this location, which makes it easy for cancer cells to escape the prostate in this area. Check your pathology report to see if you have cancer at the apex because this is the most common place for positive surgical margins, meaning cancer cells are cut across and left behind after Radical Prostatectomy. The fourth method is an invasion into the seminal vesicles, which are attached to the top of the prostate.
The finding of perineural (meaning “around the nerve”) invasion helps identify a greater chance of cancer cell leakage through the capsule to outside the prostate (called microscopic capsule penetration) and a lower cure rate. A man has two sex nerves. One runs along the right side of the prostate and the other along the left. Branching off these two large nerves are many smaller nerves that go through the prostate capsule or shell in a “tunnel” and enter the prostate. The smaller nerves have a space around them called the perineural space. Cancer cells in the prostate can get in the perineural space and use it as a “tunnel” to travel and escape through the capsule and grow and spread outside the prostate.
We can look this up in the Partin tables. For your particular case of prostate cancer with a Gleason score of 4+3=7, PSA 4.3, and stage T1c, your chance of having microscopic capsule penetration is 40%. So, you actually have a 40% chance that your cancer has progressed to step 2 growth and that you have T3 cancer, not T1c.
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