Friend's post RRP pathology report stage T0 ?!?

BTW, does anyone knows how do they examine the prostate after surgery?
I mean, they obviously can't see everything... Do they cut some peaces and look under the microscope?

Thanks!

Hi Perineum:

Actually, this is the second time (as I recall) that I have heard about this on this forum, i.e. biopsy with cancer, post-surgery pathology with no cancer.  T0 certainly means no evidence of a tumor and it is very unlikely that a post surgery pathology would miss a tumor since the tissue examination is pretty thorough as evidenced by James' response.  So, IF the post surgery pathology is correct, it most likely means the biopsy pathology was incorrect or that the biopsy removed the only 3 G8 cancers in the entire gland (very unlikely). 

This demonstrates (once again) the value of having one's biopsy slides read by an expert like Epstein or Bostwick.  What a shame (crime?) it would be if your friend's biopsy slides were read incorrectly and he was cancer free or only pre-cancerous all the time!

I guess if it was me, I would insist that both the biopsy and post-surgery pathology be sent to an expert lab so that the truth can come out.

Tudpock (Jim)

Fairwind, are you serious???
You think that it could be a mistake??

Didn't you hear about such cases? I couldn't find on the internet, but maybe I didn't search too well...


Who will pay for the DNA test you mention?
Can he demand the hospital to do it?

BTW, I think that he did take the biopsy for a second review...

"Fairwind, are you serious???
You think that it could be a mistake??"

Pathologists are human beings. Human beings are prone to make mistakes. Several different people handled those tissue samples. Medical Labs are very busy places, dozens if not hundreds of prostate tissue samples processed everyday. Mistakes can happen...

To be SURE what of happened, both samples, the original biopsy and the post surgery biopsy, should be DNA checked to be certain they are both your friends tissue...Gleason 8 in 3 out of 12 cores does not just go away...Just My Humble Opinion..

Perineum said...
Piano,
Time between biopsy and surgery (why is it matter?) was 2 months.
What do you mean by changing lifestyle?
He was drinking pomegranate juice every day because he heard it helps to stop the cancer... He started drinking it after biopsy... Can it be the reason ?!?!?

By "changing lifestyle", I meant changes to things like diet, supplements, exercise, prayer ~ all the myriad alternative therapies that we discuss (argue about!) here.

If your friend has made some change(s) that actually worked in his case, then that could explain the results. So here's a hypothesis (which I like, being a pomegranater myself!):

At biopsy, your friend had a few/several/many small spots of Gleason 8 and lower grades. Based on credible research, he started taking pomegranate. Two months elapse, time for the pomegranate to do its stuff, and now the remaining spots of cancer have gone.

Of course, by no means conclusive, but another hypothesis to place alongside some kind of medical screw-up.

Hi Perineum & ALL, - There is quite possibly something wrong here. PERHAPS, Laboratory error! I would like to see the formal Pathology Reports, both biopsy and post-surgical, and if he does not have copies of them, he should acquire them from his Urologist/Surgeon. The Pathologic findings are, almost always, much more accurate than Biopsy findings, IFdone on the same patient.

It is highly unlikely that a Gleason 8 would just disappear and since the "pathologic" (post-surgical) results are much more accurate than the "clinical" (Biopsy) findings, it is equally unlikely, that it would not be found after Radical Prostatectomy unless it is an extremely tiny spot, which is less likely with Gleason Score=8 tumor.

Concerning Prostate pathology: Over-simplifying, the Prostate is normally, separated into thin slices, inked, stained and examined under a microscope by the Pathologist.

Some investigation should be conducted here, to confirm the veracity of this unusal anomaly. In my layman’s opinion, it is quite possible that something's not right here, BUT it is also possible that it falls into a relative rare and unusual finding known as “vanishing PCa”. Here are some Abstracts that address this phenomena that, overall, appears to be found to exist in slightly less than ½ of 1% (0.004) of Prostate specimens examined at Johns Hopkins, including 2nd opinions.

#1
“American Journal of Surgical Pathology:
January 2009 - Volume 33 - Issue 1 - pp 120-125
doi: 10.1097/PAS.0b013e318185723e

Detection of Cancer in Radical Prostatectomy Specimens With no Residual Carcinoma in the Initial Review of Slides
Duffield, Amy S. PhD*; Epstein, Jonathan I. MD* † ‡

Abstract

Background: Radical prostatectomy (RP) specimens occasionally contain no carcinoma in the initial slides of an entirely submitted specimen, but no protocol has been established to assess for carcinoma in the remainder of the specimen.
Design: We evaluated 34 cases with no carcinoma in the initial slide review of the entirely submitted RP over a 2-year interval out of 2200 RPs. Our sequential protocol for cases with no initial tumor is (1) review the biopsy; (2) do immunostains on suspicious foci; (3) perform levels on blocks with high-grade prostatic intraepithelial neoplasia; (4) perform 3 levels on the posterior sextant and adjacent sextant region where cancer was identified on biopsy; and (5) flip the blocks in these regions and perform 3 additional levels.
Results: The mean age was 58.1 years (41 to 69 y) with a mean prostate-specific antigen level of 5.9 ng/mL (0.8 to 19 ng/mL). On review, all of the biopsies had carcinoma with a Gleason score (GS) of 3+3=6. The number of positive cores was 1 [n=29 (85%)], 2 (n=3), 3 (n=1), and 4 (n=1). Fifty-nine percent (20/34) of the biopsies had immunohistochemistry (IHC) for basal cells and/or α-methylacyl CoA racemase. RPs on average weighed 73.6 g (36 to 155 g). Of the 34 cases with no initial cancer, cancer was found in 26 (76%), and 8 (24%) had no residual carcinoma despite extensive leveling in all cases and IHC in 1 case. IHC was performed on 12 of the 34 RP cases. Of 26 RP cases with cancer, 22 had cancer on only 1 slide, and 4 had cancer on 2 slides. All of the cancers in the radical prostatectomies were GS 6, and the GS agreed with the corresponding biopsy in all cases. In 83% (20/24) of cases that specified laterality in the biopsy, RP carcinoma was ipsilateral to carcinoma in the biopsy. In 93% (14/15) of the cases that specified sextant site in the biopsy, the location of the carcinoma in the RP was in the same or the adjacent inferior-superior sextant site. Of the 29 cases that required leveling, in 7 cases cancer was found only after flipping the blocks and doing additional levels. Of the 8 cases with no cancer, all biopsies had only 1 positive core with 6/8 having <10% of the core involved.
Conclusions: In about 1.5% of RP cases no tumor will be seen in the initially entirely submitted specimen. A methodical limited targeted approach to identifying cancer can identify cancer in 73% of the cases with no initial cancer, yet there will still be 0.4% of all RPs where cancer is not been identified. As cancer was seen in areas away from the biopsy site in some of our cases with minute tumor, leveling all the blocks may have identified cancer in some of the cases in which we found no tumor with our protocol.


#2
Little or no residual prostate cancer at radical prostatectomy: vanishing cancer or switched specimen?: a microsatellite analysis of specimen identity.
Am J Surg Pathol. 2005; 29(4):467-73 (ISSN: 0147-5185)
Cao D ; Hafez M ; Berg K ; Murphy K ; Epstein JI
Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
With more vigilant screening for prostate cancer, there has been an associated increase in patients with little or no residual cancer at radical prostatectomy after an initial diagnosis of minute cancer on needle biopsy. This raises a critical question as to whether the biopsy and subsequent radical prostatectomy in these patients are from the same patient. We used PCR-based microsatellite marker analysis to perform identity test in 46 men (35 with minute cancer and 11 with no residual cancer). Of them, 41 were interpretable, including 31 with minute cancer and 10 with no residual cancer. All 31 interpretable cases with minute cancer showed match between the initial biopsy and radical prostatectomy specimens. Nine of the 10 interpretable cases with no residual cancer showed match and 1 showed mismatch. The remaining 5 cases (4 with minute cancer and 1 with no residual cancer) were considered uninterpretable due to technical problems. The initial biopsy of the mismatched case had high-grade cancer (Gleason score 4 + 4 = 8) measuring 9.6 mm in length with perineural invasion. Our results confirm that, in most cases of "vanishing cancer" in radical prostatectomy specimens, it reflects a chance sampling of a minute cancer and not a switch in specimens. However, specimen switch can rarely occur, and if there is high grade or a lot of cancer on the biopsy with no or very minimal cancer in the radical prostatectomy specimen, one should evaluate for patient identity.
=============================================================
#3

Vanishing’ prostate cancer in radical prostatectomy specimens: incidence and long-term follow-up in 38 cases

• David G. Bostwick, Kathleen C. Bostwick
Article first published online: 24 JUN 2004
DOI: 10.1111/j.1464-410X.2004.04900.x
Issue

BJU International
Volume 94, Issue 1, pages 57–58, July 2004

OBJECTIVE
To determine the incidence and long-term follow-up of the ‘vanishing cancer’ phenomenon, as complete sampling of some radical prostatectomy (RP) specimens reveals no residual cancer.
MATERIALS AND METHODS
The Mayo Clinic prostate cancer RP database for 1966–1995 was searched for all cases in which there was no residual adenocarcinoma (pathological stage pT0). Each case was confirmed by a review of all tissue specimen slides. Various clinical and pathological features were evaluated, and the follow-up obtained for all patients.
RESULTS
Among 6,843 RPs, there were 38 in which no residual cancer was identified despite careful sampling. There was a 10-fold decline in the incidence of this finding, from 2.1% before 1980 to 0.2% in 1993–95; this decline appeared to be caused by a decrease in the frequency of diagnosis of cancer by transurethral resection from > 10% before 1990 to < 2% in 1993–95. The mean (range) age of the patients was 63 (38–75) years. All cancers on biopsy or transurethral resection were well or moderately differentiated; clinical stages included T1a (42% of cases), T1b (45%) and T2 (13%). Six patients had a nerve-sparing RP, all after 1990. The mean follow-up was 9.6 (1.0–28.5) years, and there were no recurrences of cancer; the serum prostate specific antigen concentration remained at < 0.2 ng/mL in surviving patients. Six patients (16%) died from intercurrent disease.
CONCLUSIONS
The incidence of ‘vanishing cancer’ declined between 1966 and 1995, probably as a result of the decline in the use of transurethral resection, occurring in 0.2% of RPs. The prognosis in such patients is excellent, indicating that there is no apparent clinical significance to microscopic foci of cancer that remain undetected after reasonably complete pathological sampling. The inability to identify cancer in a prostate removed for biopsy-confirmed carcinoma does not indicate technical failure.”
There are otherexamples, but I think these are representative and from reliable sources. I hope this has proved helpful and enlightening! – John@newPCa (aka) az4peaks

It is in the realm of possibility, but not probability, that a Gleason 8 in 3 of 12 cores is going to go away.

Regrettably, many specimen identification errors occur with biopsy samples.

According to Medline, a review  that Mayo Clinic did on specimen labeling errors showed 765 labelling errors out of 8,231 bottles.

After instituting a Radio-Frequency tag to label pathology specimens, the error rate went to 46 bottles out of 8,539 bottles.

At my biopsy, done in the urologist's office,  I checked the bottles to ensure that they were correctly identified.  And my slides were also sent to Dr. Jonathan Epstein's lab at Johns Hopkins for a second opinion

Hi Fairwind and Tim G. - Perhaps you didn't read what I said in my Post, but I addressed several considerations. These quotes are all from my Post, to which you responded and in which I, also, let people know about the rare anomaly of "Vanishing PCa" while providing scientifically based, related abstracts containing informative data since not one of the previous Posters had mentioned that possibility, I thought they might be unaware.

My goal is to educate and inform, based upon what I have learned over 13 years of daily study of the medical literature relating to the subject, and personal contact with over 2,000 patients worldwide..

"There is quite possibly something wrong here. PERHAPS, Laboratory error! I would like to see the formal Pathology Reports, both biopsy and post-surgical, and if he does not have copies of them, he should acquire them from his Urologist/Surgeon. The Pathologic findings are, almost always, much more accurate than Biopsy findings, IF done on the same patient."

"It is highly unlikely that a Gleason 8 would just disappear and since the "pathologic" (post-surgical) results are much more accurate than the "clinical" (Biopsy) findings, it is equally unlikely, that it would not be found after Radical Prostatectomy unless it is an extremely tiny spot, which is less likely with Gleason Score=8 tumor."

"Some investigation should be conducted here, to confirm the veracity of this unusal anomaly. In my layman’s opinion, it is quite possible that something's not right here, BUT it is also possible that it falls into a relative rare and unusual finding known as “vanishing PCa”."

Just in case you missed them! - [email protected] (aka) az4peaks

Now what will happen if this patient has a "recurrence"?

John (az4peaks)--

Thanks for your response.  I did read your knowledgeable post about research related to this subject.  I was responding to the original poster with information about  a Mayo Clinic biopsy-error study that may explain the anomalous, contradictory results.

We had a poster here several years ago who had a small amount of cancer found in his biopsies whose post-surgical biopsy found no cancer.

I am surprised to see that in the study you quoted, that pomegranate juice drinkers PSA doubling-time decreased in some subjects and PSA increased in others.  I am not a p-juice drinker myself, but I know there are a number of people who consider it the Holy Grail of prostate cancer preventive measures.  

 

 

Many years ago, my uncle was diagnosed with 'slow leukemia' (in Britain), hospitalized for tests as he felt very unwell.

The doctors told my aunt to take him on vacation, as he was depressed, it wasn't his leukemia making him sick.

He died laying on a lounge, after a grueling drive to the coast. He was on vacation for about 20 minutes before expiring.

When she got home, there was a bright red sticker on her door, asking her to bring him back immediately.

While he was in the hospital, there was another fellow with the same name and the blood samples had been mixed up.

Unfortunately, human error is a huge problem in hospitals everywhere.

Last time I had major surgery, the surgeon came in and autographed the area before going off to scrub.

Without the autograph, you were not allowed into the OR, just another measure to cut down on errors.

Hope someone gets this sorted for your friend, be sure to check if there were two men with the same name with samples in the lab.

Mary

http://urology.jhu.edu/newsletter/prostate_cancer58.php