Post-Op Consult & Catheter Removal

56% of positive biopsy cores and post surgery Gleason 8 stage 3a is has a high chance for recurrence. In a few weeks you will get your first PSA test.

Duck2 said...
Gleason 8 stage 3a is not a good report. In a few weeks you will get your first PSA test.

Well aren’t you a ray of sunshine?! It’s the best news I could have expected based on the MRI and biopsy. It’s what I was prepared for, and I was afraid it would be worse.

But thanks for the encouraging words. SMH

Your positive attitude will go a long way and serve you well! However, some men's post-op path status is such that they benefit greatly from adjuvant RT. You can talk to your docs about this -- it's not treatment some time in the future for a recurrence that occurs, but is usually done after a few months' healing time regardless of PSA status. It should be thought of as completing your primary treatment so as to prevent any recurrence. Primary treatment, whether RP or RP + RT, is done with curative intent.

Djin

Geetar...I fully agree with you. Continue to heal from your surgery and enjoy your summer. I love your attitude!

Gman, I think it's a good report. The G8 is confirmed, and the written pathology report will have the details about which subscript on the T3 you get. Negative margins is what you want to see. The PSA in 3 months will tell much of the tale. In the mean time heal up! Did he start you on viagra/cialis? It will help the overall healing as well, because it helps pelvic blood flow. And, who knows, maybe other things will stir....

Sorry to pee on your parade.
My pathology was identical to yours, G8-3a->50% biopsy cores, and thought I was out of the woods until I got reading more. There are some that consider this very high risk.

Talk to your URO. The recommended treatment now is radiation and 6 months ADT and Casodex. If you want to go more aggressive 24 months ADT.

Post Edited (Duck2) : 5/28/2021 2:01:22 PM (GMT-6)

I am talking to my uro. Talked to him today. I will get my ‘recommended treatment’ advice from the very fine doctors at M Health. I know my risk of reoccurrence is very high and that additional treatment is probably inevitable.

I am happy today that my margins were negative, and although I did get a bit of an upgrade, it could have been so much worse. Hence it was a good report from my perspective.

I have been on this forum since 2014. I am very well aware that my numbers put me in the ‘very high risk’ category. We are all here to support each other I hope. If not I’ll need to quit coming here.

You've had encouragement coupled with honesty. No harshness whatsoever, in my view.
Anyway, HW sure shines through wonderfully on this thread.

I suspect you will be in a holding pattern until your first (maybe first two PSAs).
Please keep us informed.

Mel

Sorry for being a whiny b****. Apologies to Mr. Duck.

For the record, I did send a question to my uro concerning guidance on Adjuvant RT, or possible other treatments, regardless of 3 month post-op PSA. I will report back and possibly seek a second opinion. I'm 90 miles from Mayo and I've been a patient there before.

Here's the full path report. I know it is not a 'good' report, but it was good in my mind because I was afraid it was going to be worse. My primary fears were an upgrade to G9 or G10, lymph node involvement, and positive margins. I knew going in that the cancer was outside the capsule, and I knew about the SVI. So in my OP, when I said it was a 'good report', it was in that context.

So here it is and honest opinions are welcome, I don't need anyone to sugarcoat anything, but I know I still have a chance, however small, to beat this, and if not, to at least keep it at bay for a very long time.

Begin Path:
SPECIMEN(S):
A: Prostate and seminal vesicles
B: Bilateral lymph nodes

FINAL DIAGNOSIS:
A. Radical Prostatectomy with seminal vesicles:
(additional mTuitive synoptic report in comment section of report)

Specimen
Procedure: Radical prostatectomy
Prostate Size: 4 x 4 x 3 cm
Prostate Weight: 55 gm
Lymph Node Sampling: Pelvic lymph node dissection

Tumor
Histologic Type: Adenocarcinoma (acinar, not otherwise specified)
WHO Group 4 (see comment section)
Gleason Pattern:
Primary Pattern: Grade 4
Secondary Pattern: Grade 4
Tertiary Pattern: Grade 5
Total Gleason Score: 8

Extent

Tumor Quantitation
Proportion (p%) of prostatic tissue involved by tumor: 10-15%
Tumor Size (dominant nodule, if present): Greatest dimension:
2.0 cm
Extraprostatic Extension: Present: Focal. Right prostate
Seminal Vesicle Invasion: Present Right

Margins: Margins uninvolved by invasive carcinoma

Accessory Findings
Treatment Effect on Carcinoma: Not identified
Lymph-Vascular Invasion: Not identified
Perineural Invasion: Present

Pathologic Staging (pTNM)
Primary Tumor (pT): pT3b: Seminal vesicle invasion
Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
Number of Lymph Nodes Examined: 4 (Specimen "B")
Number of Lymph Nodes Involved: 0

Ancillary Studies: PSA 3.53

B. Bilateral lymph nodes:
- Negative for malignancy in four lymph nodes identified.

COMMENT:
This case was seen in intradepartmental consultation.

The template for prost
ate cancer on needle biopsy was adapted from the
following references.

In 2016 the World Health Organization adopted a new system for grading
prostate cancer (reference 2) with the
benefits of (a) more accurate grade stratification than the current
Gleason system; (b) simplified grading
system of 5 opposed to multiple possible scores depending on various
Gleason pattern combinations; (c) lowest
grade 1 as opposed to current practice of Gleason score 6, with the
potential to reduce overtreatment of
indolent prostate cancer.

The new grading scheme correlates with the prior Gleason grading system as
follows:

Grade Group 1 = Gleason score 6 or less
Grade Group 2 = Gleason score 3+4=7
Grade Group 3 = Gleason score 4+3 = 7
Grade Group 4 = Gleason score 8
Grade Group 5 = Gleason score 9-10

REFERENCES
(1) College of American Pathologists Cancer Protocols and Checklists, June
2012.

(2) Epstein JI, Zelefsky MJ, Jsoberg DD, et al. A contemporary prostate
ca
ncer grading system: A validating
alternative to the Gleason score. Eur Urol (2015)

Report Name: Prostate - Radical Prostatectomy
Status: Submitted Checklist Inst: 1 Last Updated By: R David
Dexter, M.D., 05/27/2021 18:05:41
Part(s) Involved:
A: Prostate and seminal vesicles

Synoptic Report:

SPECIMEN
Procedure:
- Radical prostatectomy

TUMOR
Histologic Type:
- Acinar adenocarcinoma
Histologic Grade
Grade Group and Gleason Score:
- Grade group 4 (Gleason Score 4 + 4 = 8)
Percentage of Pattern 4: 70%
Percentage of Pattern 5: 1%
Intraductal Carcinoma (IDC):
- Not identified
Extraprostatic Extension (EPE):
- Present, focal
Urinary Bladder Neck Invasion:
- Not identified
Seminal Vesicle Invasion:
- Present
- Right
Treatment Effect:
- No known presurgical therapy

MARGINS
Margins:
- Uninvolved by invasive carcinoma

LYMPH NODES
Number of Lymph No
des Involved:
- 0
Number of Lymph Nodes Examined:
4

PATHOLOGIC STAGE CLASSIFICATION (PTNM, AJCC 8TH EDITION)
Primary Tumor (pT):
- pT3b
Regional Lymph Nodes (pN):
- pN0

CAP eCC February 2020 Annual Release

Electronically signed out by:

R David Dexter, M.D.

CLINICAL HISTORY:
62 year old male with prostatic CA on prior biopsy Gleason 4+4 (U21-3585)

GROSS:
Two specimen containers with formalin are received labeled with the
patient's name, date of birth, and medical
record number. Information on the requisition slip, containers, and
associated labels is confirmed.

A: The specimen is designated "prostate and bilateral seminal vesicles"
consisting of a 55 g 4 x 4 x 3 cm4 cm
apex to base, 4 cm medial to lateral, 3 cm anterior to posterior prostate
with attached left and right vas
deferens and seminal vesicles. The prostate is inked as follows: Right-
blue, left- black. Please note bile
ink was inadvertently applied
to the left base prostate. The apex and
base margins are shaved, sectioned and
submitted. The remaining prostate is serially sectioned from apex to base
to reveal a yellow-tan fibrotic cut
surface with no distinct mass or lesion. Representative sections are
submitted.

Summary of Sections:
A1 - right apex prostate shave, perpendicular sections
A2 - left apex prostate shave, perpendicular sections
A3 - right base prostate shave, perpendicular sections
A4 - left base prostate shave, perpendicular section (Violet ink present)
A5-A7 - right anterior prostate, submitted from apex to base
A8-A10 - right posterior prostate, submitted from apex to base
A11-A13 - left anterior prostate, submitted from apex to base
A14-A16 - left posterior prostate, submitted from apex to base
A17 - junction of prostate to right vas deferens and seminal vesicle
A18 - junction of prostate to left vas deferens and seminal vesicle

B: The specimen is designated "bilateral lymph node" consi
sting of a 5 cm
aggregate of yellow lobulated soft
tissue. Sectioning reveals five lymph nodes, ranging in size from 0.4-3.5
cm in greatest dimension. The
lymph nodes are entirely submitted.

Summary of Sections:
B1 - two lymph nodes, intact
B2-B3 - one lymph node, sectioned
B4-B5 - one lymph node, sectioned
B6-B9 - one lymph node, sectioned (Dictated by: Jenne Rempel 5/24/2021
11:22 AM)

MICROSCOPIC:
Microscopic examination was performed. (Dictated by: R. David Dexter, MD
05/27/2021)

The technical component of this testing was completed at the University of
Minnesota Medical
Center-Fairview-University West, with the professional component performed
at the Fairview Southdale Hospital
Laboratory, 6401 France Avenue South, Edina, MN 55435-2199 (952-924-5152)

CPT Codes:
A: 88309-GM9
B: 88307-GM7

COLLECTION SITE:
Client: FV Southdale Medical Center
location: SHOR (S)

Gman - You are living my experience. The bladder and plumbing is a little messed up from constant catheter draining or so it is getting used to the new situation. Sounds like you will do ok once that part settles down. A yawn would get me at first when a cough did nothing. The first time my wife touched me there, a little spurt occurred. No idea why the odd things happened as I was continent otherwise and in underwear within a week.

Our path’s our similar and I opted for ART at 5 months. Takes a long time to make that decision but that is after the three month PSA when you have a value and are healed up. ED and continence are another factor since it is best to have those working before ART.

Keep up the great recovery and enjoy a nice Memorial Day weekend in MN.

I'm not understanding why your Gleason score isn't G7 (4+3) with tertiary 5 (1%). If your cancer was 70% pattern 4, that means 29% of the cancer was pattern 3 and should be listed as the 2nd most predominant pattern, making you 4+3 with tertiary 5. I would ask about this at your next meeting.

Pattern 3 is not mentioned when it is a tertiary pattern (i.e. <5%), for example with 4+4 a pathologist won't bother mentioning any 3 if it is <5%, since it is inconsequential. So normally a grade of 4+4 means pattern 4 accounted for at least 95% of the cancer. The bottom line is that either there 8s an error in the report report (unlikely), or my understanding of the numbers is wrong (much more likely).

Please let us know the error of my logic if you find out. Thanks!

(Also, the number of G7 cores in your biopsy speaks of a quite high statistical chance of being one of the nearly 50% of men who have their biopsy G8 downgraded to G7 after RP. The simple reason is that a biopsy grade is that of the highest grade lesion, whereas any pattern 3 more than 5% gets you the downgrade looking at the whole prostate ).

Djin

Yes, tertiary garde 5 has been the subject of a few recent studiesm, and the consensus appears to be that it's risk regarding BCR is about equal to the next higher grade, so 3+4 tert. 5 is about equal to 4+3 with no 5.

GM's percentage pattern 3 is hardly insignificant! 4+3 tert 5. isn't unusual. Most but not all pathologists assign a tert.pattern when it is <5% and when is has significance for the grading.

I think something is amiss. The tert. 5 in his pattern isn't the issue IMO -- it's what the secondary pattern should be.

Djin