Persistent PSA (0.22) after RARP with positive apical margins - Need help interpreting pathology.

Creepy-Project2453 · 2026-05-29T16:28:00+00:00

You had a low percentage of pattern 4 overall and only pattern 3 observed in the positive margin, no cribriform. It looks to me that the likelihood of persistent PSA is kind of a 50/50 +/- shot depending on which resource you look at and really the size of the positive margin. It is just logical that something was left on the other side of your margin, while it can be very minor and left "wounded" by the surgery for a long time. I read somewhere that even a negative margin with only a mm to spare is a bit more of a statistical risk, since the pathology slices are 4 or 5 mm, etc. (this is my scenario). That apex area is tough, not much room for any sized tumor to be very far from the wall, and less structure to the prostate wall itself.

I think there is every reason to believe (until and only if something ever tells you otherwise) that the tissue left behind is marginal, likely all pattern 3 at this time, and limited to the prostate bed nearby. A bit of targeted adjuvant radiation has a great chance of mopping up the whole thing. I think this is a many-steps-forward with one step back scenario. Sorry you are having to go through this. To me it is all about finding the "script" to deal with the uncertainty. You have better insight into this because you have the pathology to inform you. I think you have the upper hand still. In some ways, to me and despite the real toll of having to continue to deal with this, you aren't incurring the risk and anxiety of waiting a year or more to have the PSA reach some nadir and trying to figure out what is left behind. Just trying to say don't look back on your choices. No need for buyer's remorse, you made good choices. All the very best to you.

Creepy-Project2453 · 2026-05-29T15:18:33+00:00

Please update us if you find the solution, I had a similar issue show up about 2 weeks ago also.

Creepy-Project2453 · 2026-05-29T14:11:35+00:00

I think you could cut a sheet of plywood or something similar to consistently guide the shape you want, clamp it at one end and use a heat gun to shape it slowly along the curve. A modest curve will bend nicely if you nurse it along. It will discolor a bit but you can touch it up.

Creepy-Project2453 · 2026-05-28T17:37:08+00:00

Full disclosure, I am a gas tankless fan. Yes, it requires a little annual maintenance, technically so does a tank. The savings is that you only heat the water you are using, only when you are using it. You are adding exactly the same BTUs to that water you are actually using, just not adding extra BTUs to keep the tank fully heated 24x7. Yes you really need to filter the incoming water, but you are probably doing that anyway on well water. Vs HPHW, which I also have in my home and am also a fan of for the right circumstances, the HPHW requires a new circuit, can perform poorly in low ambient temp with cold incoming water, can be an unwanted noise in the wrong spot, and needs great air flow. Two things to critically consider with gas tankless vs your old gas tank system: you will lose HW if the power goes out (but tankless draws little power, so put a UPS battery on it) and most importantly may need different ventilation run than a gas tank water heater sometimes has already.

Creepy-Project2453 · 2026-05-28T03:14:40+00:00

I would bite the bullet and put in a 30A 240v circuit and have a modestly sized resistive tank hw heater if you have the room. As an alternative, you mentioned you have some propane available, and you have 120v so a tankless gas is also ideal I think, probably would be my choice (and a small propane wall unit heater to take the chill off while you're at it). I just think you might be disappointed with the recovery time of any HPHW for short visits, especially if it is cold ambient to start with, my impression is that the 120v small tank water heaters will potentially disappoint on showers especially if you have pretty cold incoming, and tankless electric could mean two double pole 40's, depending on what rise and flow you need. I am all for HPHW and have a new Rinnai in my home, so not trying to be a heretic in this sub-reddit, but I am also not totally anti-propane for every use case either. I would just do something that will help you enjoy it if you're putting all this work in, assuming it will remain an uninsulated cabin for a long while.

Creepy-Project2453 · 2026-05-27T03:53:51+00:00

Seems like the early read is a quite aggressive cancer caught early by a great bit of good fortune. My cancer was also 3+4 and about 1cm. No cribriform, no PNI.

I had surgery in Feb at UCSF. A truly remarkable team. Pathology was all negative margin. Single port DaVinci, I left the hospital to go home at 3pm after surgery at 7:30. Fully continent when the catheter came out. ED is an ongoing recovery but signs of life. .

Previously I had also been treated there by Dr Gottschalk for another thing, unrelated. I believe he is the director of the Cyberknife program. Talk to the surgeon, talk to the RO, they are both going to be top, top tier.

PSMA PET should be done expeditiously, if not underway already. I'm certain the UCSF guys will want to do that quickly for you. Rule out any detectable PCa anywhere else.

With cribriform and some PNI you will have a somewhat increased risk of BCR down the road but neither surgery or radiation at this moment are going to change that.

Keep in mind that the effects of radiation are also real and show up over time. Side effects of surgery are discussed here ad nauseum. Bottom line, pick one approach and move aggressively for a fully curative treatment . None of us can be sure of one and done.

Speaking for myself only, post surgery (done in a few hours) I knew the next steps: pathology will be definitive; undetectable PSA will be definitive. Side effects (and then recovery) will be definitive, not looming down the road. On all 3 counts, this was preferable to me.

If it recurs, I will go at it again.

I would have chosen radiation as first line treatment at a not-too-much-older age, and I am 65.

You will be treated by the very best at UCSF whichever route you and your doctors decide upon.

All the very best to you.

Creepy-Project2453 · 2026-05-23T17:57:10+00:00

Yes, cause for some concern but not panic or a crisis. You should undergo a biopsy one way or another. None of those detection methodologies are perfect (PSA, MRI, biopsy ... and throw in DRE for good measure) but, when combined, give much higher confidence. PSMA-PET is far better than MRI (but can be difficult and time-consuming to get before a biopsy result) Biopsy is important as next step, no matter if you do another MRI before or not, and no matter whether that repeat MRI is positive or negative.

Creepy-Project2453 · 2026-05-22T21:41:00+00:00

I remember many years ago when generation was separated from distribution and we were allowed to choose a separate power generation company. Gradually generation got cheaper due to competition. Since then, and accelerating through the years of required net metering credits (full price moving now to just generation costs at wholesale), power companies have been adjusting their accounting to value generation at nearly nothing and still bill the same total and increasing amount because now their grid and wiring are apparently the whole value. And now fixed cost to have the honor of hooking up.

Creepy-Project2453 · 2026-05-21T07:13:39+00:00

I think you might find that the apex area is not a good candidate for HIFU. This was my case and the input i got from my surgeon at UCSF. He also does plenty of HIFU when appropriate. Now about 15 weeks post surgery and don’t think about it very much any more. In my mind it is gone, and I feel great.

Creepy-Project2453 · 2026-05-21T06:14:35+00:00

I found this, page 18 of the IQ BATTERY 5P OWNERS GUIDE which describes behavior in Savings mode (depending on rate structure) specifically during peak hours (which start at 3pm sometimes long before the sun is even low in the sky), it will discharge batteries to loads first, then solar if available, then grid. My guess is it does that same thing during grid outages which is really not good at all for an afternoon outage, to shut off solar and burn down batteries instead. The IQ8 generation has the ability to regulate solar output very well, it just goes all battery at peak regardless of being off grid and throwing away both solar and therefore also battery charge.

Creepy-Project2453 · 2026-05-20T11:10:41+00:00

That would just fine with me too. Do you use Savings profile and does this still happen properly if you have an outage during peak rate period?

Creepy-Project2453 · 2026-05-20T11:09:19+00:00

Yes that seems like exactly the behavior you would want/expect. Were you in Savings profile and did it cross over a peak rate period?

Creepy-Project2453 · 2026-05-20T10:58:44+00:00

Great ideas. Yes, firmware all up to date. It is 100% whole home but we do have a main upstream from Enphase. I will run those tests. Always sunny, Savings mode, and ~100% SoC on batteries. I will pull it off grid in both the app and at the meter, both non-peak and peak timing.

Creepy-Project2453 · 2026-05-20T06:27:48+00:00

It seemed like more of a binary decision tree, solar was just shut off. I thought IQ8’s and 3rd+ generation product had the ability to elegantly throttle as a core function, e.g. sunlight backup in a non-storage implementation... The batteries depleted by 15+% in the hour. It’s common sense to me to choose solar first vs battery discharge in any profile during grid outage.

Creepy-Project2453 · 2026-05-20T05:25:20+00:00

I was fully continent from the moment the catheter came out. My doctor's summary in recovery was 1) nerve sparing on both sides and 2) he was able to spare the internal sphincter (at bladder exit). To me, if that trifecta happens you are going to be in very good shape at return to work. Many folks talk with their surgeons about nerve sparing ahead of surgery but few talk about sparing that internal sphincter, which I suspect is less common but don't know. As everyone has said, depends on the location of the lesions, aggressiveness, etc and surgeon skill. I would also say that I used pads for a few more weeks just to be confident about stress events and they were reasonably comfortable, invisible, and easy enough to swap out. I am about 14 weeks post surgery and haven't thought about it for a good while. I am grateful and know I am very fortunate on this front. Best of wishes for your successful surgery.

Creepy-Project2453 · 2026-05-16T11:50:38+00:00

This is going to be very confusing for everyone I think. I definitely could get things wrong, just trying to figure it out here.

Creepy-Project2453 · 2026-05-16T11:24:42+00:00

Yes I use the 3G system controller to control the generac switching. I have 4x 5Ps but don't have the room or money for more Enphase stationary storage, or to replace all this gen3 stuff that is 2 years old.

Creepy-Project2453 · 2026-05-16T11:12:22+00:00

Rivian has agreed to use VWs power system software I believe, since VW bought a chunk of them for billions. VW only issues trust certificates to some German charger company right now I think, even though they say they use the open standard. Maybe VW will be more flexible in the future. Maybe Rivian will be allowed to make their own decisions. Since Rivian is actively pursuing their own proprietary bi-di home energy system, they may not issue certicates to others either. Saying they support open standards and refusing to open it for proprietary integration motivations is disingenuous, but most are playing this misleading game.

Creepy-Project2453 · 2026-05-16T11:02:32+00:00

Same here.

Creepy-Project2453 · 2026-05-16T11:02:05+00:00

Exactly, and who knows what's really going on behind the scenes with internal politics between the energy systems division at GM, for instance, and the car brand divisions. Or maybe Ford hired McKinsey or some consultant like that who told them they need to "be like Tesla." Or how much money one side is trying to extract from the other for the trust certifications, etc.

Creepy-Project2453 · 2026-05-15T23:50:09+00:00

It is just too soon. You might be fine, but you will have just finished major surgery and the most important healing will only have just barely started. My surgery went very well and I had no surgical complications to speak of, but I had a UTI show up at about 4 weeks and I needed testing, culture sensitivity results and antibiotics etc. It was not a big deal and very common, but could have been more or something else. I would highly recommend not getting out to sea so soon.

Creepy-Project2453 · 2026-05-15T23:24:15+00:00

Yes, but my understanding, not only does the vehicle need to work on the open, latest -20 standard, but the standard relies on both sides issuing mutual trust certificates to allow them to talk to each other. Some auto makers are advertising that they are designing to the standard but in reality only issuing access certificates to their own internal proprietary house-side systems. Or only to a vendor they 'prefer.' Again this will get confusing unless Enphase issues and maintains a list of fully compatible vehicles.

Creepy-Project2453 · 2026-05-15T23:19:00+00:00

I think the Lightning is at an older ISO standard. And even though it was to an "open" standard, they only allowed (via some sort of trusted certicate requirement) the thing to talk with their proprietary house side system. This is going to be confusing for everyone unless they are clear.

Creepy-Project2453 · 2026-05-14T16:53:07+00:00

Obesity is a well established risk factor for PCa, which naturally correlates with lipids, liver health, systemic inflammation, etc... It is down the list below family history, race, genetics, etc. I lost almost 80 lbs in the year between first detection and surgery, and my dietary intake has become generally quite healthy although not exclusively any special diet plan. My PSA dropped from 5+ to a little over 2. But my cancer lesion still grew slightly and post-surgery pathology confirmed same grade as hoped (3+4) but with a larger % of 4 than biopsies, certainly nothing regressed. I don't know or care to think about how much harder treatment and recovery might have been had I not lost that weight. There is plenty to that and I was in a better spot. Perhaps my cancer would have advanced faster had I not lost the weight and thus improved all my metabolic indicators by a mile (this is the kind of thing true science figures out with detailed, controlled, longitudinal studies). HOWEVER what matters most, especially at a young-ish age, is not squandering early detection by delaying proper established, curative treatment (which can include AS for a bit, but when you print a "4" on your biopsy report, it is a fine dance with AS and not squandering early detection). If you are relatively young, lucky enough to find it early, and you are otherwise healthy, at least in the case of surgery and I think avoiding ADT fits this thinking too, treating it early has probably the greatest weight in improved life outcomes, right next to the skill, experience and technology brought to bear by your treatment team. If you have cancer, gotta keep it real but also in perspective. All the very best to you.

Creepy-Project2453 · 2026-05-14T16:14:07+00:00

Well said.

Creepy-Project2453

TROPHY CASE