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Posted 10/23/2013 2:40 PM (GMT 0)
My husband had an RP a week ago. Report came back and it's good news but I'm confused. Our doctor said there was a close negative margin which I understand (after reading Dr. Walsh's book). There was no perineural tumor distibution demonstrated. Under the tumor staging section -
Prostate Weight: 26.5
Primary Gleason Pattern: Grade 3
Secondary Gleason: Grade 4
Tumor Quantitation: Proportion of prostate involved by tumor: 25%
Extraprostatic Extension: Not identified
Seminal Vesicle Invasion: Not identified
Margins: Margins uninvolved by invasive carcinoma
Postero-lateral (neurovascular bundle) margin (s) involved by
Invasive carcinoma.
His post-op staging is T2c but my confusion is with the neurovascular bundle. Is this the "nerves" that were spared (according to doctor). What does this mean? If it's involved is there a margin with this? Also what does "not identified" mean - negative?
Posted 10/23/2013 2:50 PM (GMT 0)
The "neurovascular bundle" had to have been removed for them to biopsy it...yes, not identified means the same as negative..

I would ask your surgeon about the exact meaning concerning the 'bundle" reference..
Posted 10/23/2013 2:52 PM (GMT 0)
Is the neurovascular bundle the nerves that are referenced in "nerve sparing procedure"?
Posted 10/23/2013 3:07 PM (GMT 0)
Dear back2fish, welcome to HW and we hope your husband has a quick recovery from his operation.

Like Fairwind, I read this as the nerves (or at least one side) were removed, i.e. not spared if they were identified as including cancer. This is a very important thing to understand as regards his sexual recovery. But perhaps we are incorrect....

I would recommend that you call your doctor's office and ask for a complete explanation including perspective on return of sexual function if the nerve(s) were not spared.

Jim
Posted 10/23/2013 3:20 PM (GMT 0)
At first glance it sounds like a case of "partial nerve sparing" where only one side was spared due to perineural invasion. If I understand correctly, the neurovascular bundle on the side with perineural invasion is removed along with extra tissue surrounding it, as it was in my case. The other side is spared. It would be great if all pathology labs would standardize their terminology to reduce the amount of confusion in the reports.
Posted 10/23/2013 3:28 PM (GMT 0)
Welcome back2fish,

I think that you and your husband should speak to your surgeon and ask him to clarify the pathology report. My husband and I spoke with his surgeon about his report, and I also had a long talk with the PA about things I was unclear about in the report

Because the report says that the "(neurovascular bundle) margin(s) involved by Invasive Carcinoma" perhaps a portion of the nerve(s) were removed, but not all of them. My husband lost about 25% of his nerves (on both sides) during his surgery. His surgeon has a numerical rating system to quantify the amount of nerves removed during every surgery. His surgeon told us what those numbers were immediately after his surgery, and they are also in the surgical notes.
Posted 10/23/2013 3:38 PM (GMT 0)
Welcome your husband to the other side (of recovery) for me!

I made a copy of my report, highlighted the phrases I was not clear about and went over it all with my surgeon on my next visit. For such an import report, it is like reading Latin to patients.
I Googled names, checked Walsh's book but still didn't completely understand it all.

I just received my Operative Report last week, which tells what all they did during the operation and I needed Google to help me interpret everything.

Bill from Florida cool
Posted 10/23/2013 4:30 PM (GMT 0)
Thanks for all of your input. I was happy when we heard the good news and it wasn't until we got home from the doctor's office that I started reading the report word for word and that's when I started to worry again. My husband will be getting the cath out next Wednesday and I will have questions about this (as usual) if I can wait that long. When the doc talked to us after surgery and said he was able to do the nerve sparing procedure and that the surgery went very well I just assumed both bundles were spared 100%. So now I'm thinking any nerve left in there may still have cancer.

Strange how you get your mind going in one direction and then another new piece of information has you running to research it. And you think you just can't read another word or your brain will explode. Then the next day I'm back at it again. Kind of like reading a book that has no ending.

Anyway I'm a worrier but I've tried not to be in front of my husband. He's a quiet guy, doesn't make waves, unlike me. Opposites attract.

I've been getting a lot of great information and encouragement from you guys for several weeks now and appreciate it so much!
Posted 10/23/2013 5:40 PM (GMT 0)
I agree if they found cancer in part of the nerve bundle, there was at least some disection of some of the nerve bundles. Having said that perinueral invasion is not talking about the nerves that affect erection. The nerve bundles are lying over the prostate capsule and the cancer like to spread to these. perinueral invasion could be the reason but not necessarily. Perinural invasion refers to the nerves within the prostate. these nerves have nothing to do with erection capability. They give you the feeling you either like or do not like in a DRE. The nerves inside the prostate and there are many, bore a microscopic tunnel in which the cancer inside the prostate like to move into as it is the path of least resistance. When discovered on biopsy they are prognostic for possible EPE. when the the prostate has full post op pathology and no EPE is discovered, there prognostic value is diminished greatly. The prognostic value of post op PNI is controversial among the experts. the prognostic value of biopsy PNI is not controversial. It is agreed on by the vast majority of experts that it has a possibility of creating an EPE. If no EPE is found in post op pathology the PNI danger to outside spread has been mitigated greatly. The vast majority of Postop Patholgy reports PNI. The vast majority of postop cancer patients, that are capsule contained, DO NOT have recurrence. That surely indicates that PNI on post op Path is greatly prognostically mitigated. Cancer is sticky and does not have a free fall thru the tunnels the non erective nerves bore inside the capsule. What they do do[pun is probably intended} is allow freerer movement in the open space. I.E no tissue to gobble and transform. Hence a greater chance of EPE. Once post op path reveals negative EPE, the issue is mute, at least for the classic EPE. Again this is not to say That PNI is therefore not a danger, just less so. If a few higher than 6 gleason cells migrate thru these tunnels and escape locally or systemically and escape the pathology eye, well that is a horse of a different color. It would be better not to have PNI identified pre and post op, 35 to 40% post opS recure. I am maybe being more pessimistic with these stats than warranted, maybe not. I know, arguably, the percent of post op PNI, that do not recure is a lot higher than the amount of post op classically contained capsule that become recurrent. For all these reasons, the psa test is usually given post op for the duration of the patients life. Wow I must have eaten bird seed this morning, that was a lot chirping. Off to a diminishing north swell and a great day, good lord willing.
Posted 10/23/2013 6:06 PM (GMT 0)
Here is the final pathologic diagnosis of the prostate gland:
"ADENOCARCINOMA, Gleason 7 (3 + 4), tumor involves both left and right postero-lateral lobes with more involvement on the left indicated. Tumor involves the apical shaved sections on both the left and right however does not penetrate the inked margin. Tumor extends to the capsule but does not appear to penetrate the capsule or involve the inked peripheral postero-lateral margins. Sections of the right seminal vesicle are free of tumor. Sections of the basal shave sections are free of tumor on both the left and right. No perineural tumor distribution is demonstrated." Then down a little further in the report under the Tumor Staging - Margins section is written this contradictory statement "Postero-lateral (neurovascular bundle) margin(s) involved by invasive carcinoma". It's really hard to make sense of this stuff.
Posted 10/23/2013 7:20 PM (GMT 0)
Your husband's biopsy report was very similar to mine post surgery. Except I had one negative margin, which unfortunately, cause quick recurrence for me.

I hope he does well with the rest of his recovery, and hope his first post surgery PSA report gets him into the "zero" club.

Good luck to both of you

David
Posted 10/23/2013 7:57 PM (GMT 0)
The last sentence make absolutely no sense based on everything before. Here's what I did and admit it was out of protocol. probably best to ask Doctor, but you get so much CYA anymore, I went o Horses mouth. I waited till a weekend swing shift and called pathology dept my self and directly asked one of the pathologist the question of my concern,{ my issue is not relevant} to this post. But the pathologist looked up my slides and the report and graciously answered my query to my satisfaction. Perhaps that would work for you, perhaps not. All depends on who answers the phone. If nothing else press the doctor for an explanation and do not let up until you are satisfied. You must understand it and it is the doctors responsibility, not yours to to say the words in the right order so that you do. And only you can make the determination of understanding. Be of good faith, there is more good than bad in that poorly written report.
Posted 10/23/2013 11:54 PM (GMT 0)
I agree the report seems contradictory. As I understand it "involved" margins are positive margins. If a portion of the NVBs was involved but was removed, then that would be inside the inked margin so the margin would be negative (not involved).

Also, as I understand it, any NVB involvement (regardless of positive or negative margin) would be extraprostatic extension and make it stage pT3 not pT2.

Since all the rest of the detailed report up to that last sentence seems so explicit and specific, it almost seems as if the last sentence is inadvertent (e.g. a copy and past error?). Let's hope it is something like that.

Definitely ask your surgeon, but Logo has an excellent suggestion to contact the pathologist who authored the report.
Posted 10/24/2013 12:55 AM (GMT 0)
My understanding was the "Neurovascular bundle" are the nerves and blood vessels that facilitate erection. I think this link from Johns Hopkins confirms it.

urology.jhu.edu/newsletter/prostate_cancer74.php

I can only think that the surgeon realised during surgery, that that particular bundle contained tumour and therefore removed it (as he most certainly should if he thought tumour was present). This would then suggest that only the one set of nerves were preserved. But like the other members I would certainly get a better understanding from the doc or pathologist.

The Hopkins/Walsh article contains the statement.

"It takes a great deal of experience, and also tactile sensation, in determining exactly when and where it is possible to preserve the neurovascular bundle, and where it is necessary to remove it".

Later Walsh says that open surgery is the "gold standard" of treatment (surgery?)
What I want to know is how on earth any surgeon gets "tactile sensation" when doing an operation robotically.

Post Edited (BillyMac) : 10/24/2013 1:28:03 AM (GMT-6)

Posted 10/24/2013 1:13 AM (GMT 0)
njs, thanks for revealing the fact of pT3, not pT2. My understanding is that you are correct and wish I had thought that aspect thru myself. Though I do understand that it is true, my understanding of that point is mitigated by a understanding that negative margins would seem to trump any negative effect of the epe. I have never understood why it is reported as such, other than it fills the letter of the law[ it did penetrate the capsule] and not the spirit[ negative margin trumps epe prognostically], hence a moot point,that is the epe. I like word play, it has a life of its own plus its good mental exercise for those inclined to playing. Regards… Er, ah, back2fish, I hope I haven't scared you off….. tee hee. Ok I'll be good!
Posted 10/24/2013 4:18 AM (GMT 0)
I don't have anything to add...just want to say I learn so much from these posts...why can't the doctors answer these questions as we'll as u guys? Just sayn:) alison
Posted 10/24/2013 4:37 AM (GMT 0)

logoslidat said...
my understanding of that point is mitigated by a understanding that negative margins would seem to trump any negative effect of the epe. I have never understood why it is reported as such, other than it fills the letter of the law[ it did penetrate the capsule] and not the spirit[ negative margin trumps epe prognostically], hence a moot point,that is the epe.

Logo, I believe there are several studies showing that, even with negative margins, EPE (stage pT3) has a significantly higher risk of recurrence vs. organ confined (stage pT2) with negative margins.

I imagine that may be because the cells in a lesion exhibiting EPE are more likely to be invasive / aggressive compared to cells in an organ confined lesions (some of which may never be capable of EPE).
Posted 10/24/2013 3:39 PM (GMT 0)
njs, thats a very plausible theory/fact. Makes sense. I tell you, you need a college degree majoring in PCA to know and understand all the different facets of this disease that are known. A curriculum surely could be filled with those different facets. DGV Doctors get paid for their knowledge, we don't. So they parse it and we don't. lol btw, a clarification, the tunnels bored by the cancer are in fact, bored by the internal nerves themselves, which creates open space around the nerves which is the path of least resistance. I suppose at some point the internal nerves themselves are permeated with cancer.
Big Mac. You are correct. that is exactly what the nerve bundles are. I was trying to draw the distinction between the bundles and the internal nerves inside the prostate. They are what pni are referring to. Peri greek for around, neural for nerves,i.e. invasion in space around the nerves. Ok time to play space invaders , and off to play with the sharks.Actually I play with the sea turtles who protect me by drawing off the sharks and if necessary, giving up their lives. Greater love hath………. Lesson here. Do not confuse the nerve bundles referred to all the time here referencing ED with the internal prostate nerves that are referenced to perinueral invasion.
Posted 10/24/2013 6:59 PM (GMT 0)
njs & all -
Yes, I was thinking maybe a type o. Hoping anyway otherwise it doesn't make sense. I have done even more focused reading in the last day or so and with negative margins and no perineural tumor distribution then there is no EPE. Even though that wasn't what I was questioning. If the postero-lateral margin is involved with invasive carcinoma then EPE does exist. I've also noticed that some of you seem to have been provided more information from your path reports, ex. bladder neck info. Logoslidat you haven't scared me off :) ...... Just called the doctor's office and left a message. Will get clarification later today.... talked to the doctor and he agreed the statements were contradictory and that's not what he recalled when talking with the pathologist. He said he'd call the pathologist and get back to me.

The pathologist didn't have the report in front of him but from what he could recall of his conversation with the doctor is that the NVB margin was not involved. The doctor feels it may be a type-0 but the radiologist is checking the report and will inform the doctor. The doctor also confirmed that he did 100% nerve sparing on both sides so if there was no involvement of that margin I'm assuming the pathologist knows where the bundle was sitting on the prostate if all of the NVB is still intact.

Post Edited (back2fish) : 10/24/2013 1:54:29 PM (GMT-6)

Posted 10/30/2013 6:22 PM (GMT 0)
Path report had a type o to our benefit per our doctor. My husband will have his catheter removed today and we will receive the revised report today. Each time I read the encouraging, positive words in these posts I am amazed by your spirits and attitudes. You guys are really something else - thanks!
Posted 10/31/2013 2:08 AM (GMT 0)
That's great news! Good for you for picking up on the discrepancy -- 9 out of 10 people would probably not have even noticed.
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