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Domo arigato, Mr. Roboto! - Post-op pathology

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Posted 6/17/2011 3:49 PM (GMT 0)

Hey folks,

Had my follow-up exam with my urologist today, a week after my prostatectomy.  Had the catheter removed.  Then we went over the pathology report.  I got good news and I got bad news.

  • The good news:  Gleason downgraded to 6 (3+3), no seminal vesicle invasion, no lymph-vascular invasion.
  • The bad news: Extraprostatic Extension / Perineural invasion (surgical margins) present

Here is the text of the pathology report:


Diagnosis:
A. Prostate, radical prostatectomy (44 grams):
Bilateral well-differentiated prostatic adenocarcinoma, predominantly right lobe with a small amount in the left lobe; involving about 20% of the total gland; Gleason score 6/10 (3+3); showing perineural invasion , but no definite lymphovascular invasion; showing focal extraprostatic extension; showing wide involvement of the posterior surface of the right lobe; no evidence of seminal vesicle involvement.
B. Preprostatic tissue, excisional biopsy:
Adipose tissue with no evidence of tumor or lymph nodes.
C. Right pelvic lymph node, excisional biopsy:
One lymph node showing no evidence of mestastic tumor (0/1).
D. Left pelvic lymph node, excisional biopsy:
Two lymph nodes showing no evidence of mestastic tumor (0/2).

  • Pathologic staging: pT2cpN0
  • Specimen: Prostate and seminal vesicles (44 gm)
  • Procedure: Radical prostatectomy and lymphadenectomy
  • Prostate size: 3.2 x 3.5 x 3.0 cm
  • Lymph node sampling: Bilateral pelvic nodes negative (R 0/1, L 0/2)
  • Histologic Type:  Adenocarcinoma
  • Histologic Grade: Well differentiated
  • Primary Pattern: 3
  • Secondary Pattern: 3
  • Teritary Pattern: N/A
  • Total Gleason Score: 6
  • Tumor Quantitation: Bilateral, approximately 20% of total gland
  • Extraprostatic Extension: Focally present
  • Seminal Vesicle Invasion: Not identified
  • Margins: Right posterior surface, rest of margins clear
  • Lymph-Vascular Invasion: No identified
  • Comments: EPE is difficult to judge because tumor extends to the outer surface of the specimen.  The right side of the prostate shows infiltrating small to medium sized glands, extending to the posterior surface of the right lobe and focally appearing to extend beyond the prostatic capsule.  There is local slight involvement of the left side. Preprostatic tissue and lymph nodes are free of tumor.

Today's meeting with the doc seems more scary to me than the day I was diagnosed.  I feel like the cards are stacked against me.  My doctor said that a PSA test 6 weeks from now will drive what steps we take next, whether that be active survellience of my PSA or if we proceed right into radiation.  He suggested that with radiation, the odds are good I'll be able to beat this.  That may be so, but right now my wife and I are in shock and finding this hard to handle.

Posted 6/17/2011 4:16 PM (GMT 0)
John,

I just proves how variable PCa is. You have the same % involved I did, but much lower Gleason.

I suspect (just my non-medical thoughts) that the EPE was not clear enough to kick you straight over to RT (mine was, and did).

You are correct - mixed news. But the lymph nodes and seminal vesticles being clear is very good.

Work on getting healed for the next 6 weeks. That is your priority.

Posted 6/17/2011 5:14 PM (GMT 0)
John,
I felt much the same way when I got my path report although yours is better. 142 is right...just work on healing right now. There is a lot of good news in that report too, so don't let the bad overwhelm the good. If you plug your numbers into the Sloan-Kettering model you will see that your odds are still extremely good: http://nomograms.mskcc.org/Prostate/index.aspx
I'm still wressling with the ART vs. SRT approach but my Uro doesn't want to go the ART route. Odds are we will be having that discussion again next month when I see him. Take it easy and try your best to remain calm. Reading up on all this may help although you need to find distractions too. Keep the faith, brother...
-Bob
Posted 6/17/2011 6:35 PM (GMT 0)
John,as Bob said,work on the healing. The rest will work out. I thought I was going straight to radiation, but so far so good. Every case is different and things change, just look at my stats. Over thinking will just make ya nuts and loose lots of sleep!
Posted 6/17/2011 8:13 PM (GMT 0)
From a newbies view, it seems the good far outweighs the bad right now. Like others have suggested, I would concentrate on healing for now. Hug the wife and help her to help you. The both of you can handle this until you know more. Catherter out already! Wow, good for you.
Posted 6/17/2011 11:30 PM (GMT 0)
JOHN:
as other said -focus on healing - and try to put the path report away for a while - reconnect with your wife and family and focus on a long future together...
ie. think positive all will be negative in time...
-just check out my stats - PCa and docs don't always follow the same pathway..
wishing you all the best,
hugs
BRONSON
Posted 6/18/2011 2:55 AM (GMT 0)
HD:  One thing that jumps out at me is that the only cancer found was Gleason 3, which is significantly better than if they had found Gleason 4 with EPE, I think.  Also the volume was relatively low.

I know it's not the pathology you wanted, but let's wait and see what the PSA looks like in a few months.  Hopefully, it will turn out to be undetectable.  Here's wishing  you all the best.  Try to relax and enjoy this Father's Day weekend.

Posted 6/18/2011 7:51 AM (GMT 0)
First of all, relax -- whatever the situation is, you will deal with it.

Most Extraprostatic Extensions are microscopic -- measured in 1/10ths of a mm. This means that any cells that were left were cut off from their blood supply and are already dead.

You have joined the wait, watch and worry about your PSA club, This is not a fun group, but most of our worry is baseless.
Posted 6/18/2011 8:09 AM (GMT 0)
This path report is one of the best I've seen in terms of the layout and explanation.

Good news is the down grade from 7 to 6, believe me: that's fasr far betetr than an up grade from 6 to 7.
Clear lymph nodes and seminal vesicles are good news too.

The EPE is described as focal: my uro said that meant it was small so that it showed up on a microscope slide, but was not obvious to the naked eye, whioch means less volume, which is sort of good news.

The PSA test at 6 weeks or so is going to tell you something much more useful. I know how difficult it is to try and not worry about everything during this period, but at this point there is nothing you can do to change what your PSA is going to be, so it is far better to invest time and energy in improving your general health/recovery/incontinece etc. The fitter you are physically the easier many aspects of your future will be.

Alf
Posted 6/18/2011 1:23 PM (GMT 0)
John:
Your post-RP psa will be undetectable. Your surgeon did a fine job. The only chance of spread is in a minute area. G6 has a difficult time surviving the trauma of surgery. You have at least two other swings left in this time at bat. Men with your pathology live long (looong) and productive lives.
Posted 6/18/2011 1:31 PM (GMT 0)
I feel your concern.

However it is true that:

1.  PCa may not survive the trauma of surgery

2.  PSA may never rise

3. You will have drinks at the zero club

4. If PSA does rise, good probability that second line of defense will stomp it out.

Try to relax when possible, stay active (within reason),

and soon I will be meeting you in the Zero Club.

 

Posted 6/18/2011 11:30 PM (GMT 0)
One thing I don't quite understand. If my pathology report indicates Extraprostatic Extension / Perineural invasion (surgical margins) present, why was my staging determined to be pT2cpN0? Shouldn't I have been staged at pT3 ?

I'm trying not to dwell on this, but I am looking for answers.
Posted 6/18/2011 11:39 PM (GMT 0)
I don't think perineural invasion would affect the staging one way or the other, but I was a bit surprised that the EPE didn't result in a PT3. I thought that would usually be the case, but maybe the EPE was so slight that they didn't feel it justified the pT3 staging. Just guessing.
Posted 6/19/2011 1:10 AM (GMT 0)
Same here, I thought it was a typo on your part.

The prostate staging doesn't match pathology.

On my reports front page brief it lists 4+3=7

On the detailed pathology pages behind it, it lists it

as 3+4=7.  When I see my uro for PSA I am going

to bring it up.  Hope we did'nt have knucklehead

pathologists.  I am concidering a second opinion

with Sloan.

Posted 6/19/2011 1:27 AM (GMT 0)
http://pathology.jhu.edu/department/services/secondopinion.cfm

http://www.mskcc.org/mskcc/html/105.cfm

 

Posted 6/19/2011 2:09 AM (GMT 0)
Sag - I was considering getting a second opinion on the pathology report, but what would be gained by it other than piece of mind? I mean, isn't it the initial post-op PSA that drives what further therapies might be needed, if any? Would the post-op pathology report have a bearing, in conjunction with the PSA, what therapies (adjuvant or salvage) might be needed? And if the second opinion report disagrees with the first pathology report, what then?

The Sloan-Kettering post-op prediction tool highly suggests that I'll be just fine (thanks, Bob!) but that is based on my current pathology report. Part of me says to "let it be" and wait for the PSA test. But I've never been one to sit on my laurels and let things happen; I'm a controlling S.O.B. Just ask my wife!
Posted 6/19/2011 11:31 AM (GMT 0)
Thinking the same, what would the purpose of a second opinion at this stage.

I look at my URO as a Jedi, everyone else at the hospital are Star Wars bar creatures.

I under estimated the value of a good pathologist.  Focus was on treatment/surgeon

choice.  My URO had control over biopsy pathology since he had his own biopsy center.

Sent it to a lab 40 miles away.  His office is across the sreet from the hospital.  He did the

surgery in the hospital, and the pathology was done at the hospital.

My thinking is that if my PSA ever rises, I would strongly question the Star Wars bar

scene creatures pathology.  Should I do it now, wait ? not sure.  We are basing our

fears/happiness on a pathology as if it were written in stone.  In my case I believe

it was written on toilet tissue. 

Posted 6/19/2011 12:49 PM (GMT 0)
At this juncture, it seems like we are in a similar boat, some with better numbers than others but the choices that lie ahead are the same. Wait and see if a PSA rise occurs or consider Adjuvant therapy. Another factor I'm dealing with is the level of sensitivty of PSA testing. Around here, we only seem to test to the first decimal point (tenths)but many others seem to get ultrasensitive testing which goes to the second decimal point(hundreths). Seems like a lot of valuable information could be lost with less sensitive testing and that bugs me...feels like I'm getting the Chevy level of care when the Cadillac level is what I want. Additionally, regardless of whether my Uro wants to refer me or not, I may pursue a consult with an MO or RO just to get their take on my case and ART vs. SRT from someone other than my Uro. It's not that I want to go through radiation at all but I do want to do all I can to increase my odds of long term survival. Problem is it's not without its risks and QOL issues must also be seriously considered. I'm a control freak too so I understand John's feelings on this one. Also, if you play with the Sloan-Ketterring calculator, you can try running the numbers several ways and you may notice that the numbers don't change dramatically. I had first thought my margins were negative, very close, but negative. The Uro corrected me that because it was so close it would be considered positive. I didn't like hearing that, but when I used the model it only changed the odds of recurrence by a few percent. So, it is what it is...the question is, where do we go from here?  If anyone knows of any studies on the risk-benefit analysis between ART vs. SRT, I would like to read them. 
Posted 6/19/2011 5:24 PM (GMT 0)
Agreed, PSA is the only issue now.  There would be no

point on a Post Surg Pathology.  We are feelng the PSA

anxiety, so many here  talk about.  Oh well, but hey,

save a seat for me and rider.

Posted 6/19/2011 8:05 PM (GMT 0)
You got it brother....consider those seats saved!
Posted 6/21/2011 1:56 AM (GMT 0)
Seats saved and beers chilled!
Posted 6/21/2011 10:35 AM (GMT 0)
Thanks, ah yes, a crisp chilled beer to celebrate a zero, can't wait eyes

 

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