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post radical prostectomy extraprostatic extension, but

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Posted 3/9/2022 1:44 PM (GMT 0)
Just got my post pathology report and am confused by one thing. Margins, lymph, and seminal vesicles all negative and it says capsule intact. However, it also says non-focal extraprostatic exension, grade tc3aNO. How can that be if the capsule is intact? And for what it is worth, my MRI said "organ confined".
Posted 3/9/2022 2:30 PM (GMT 0)
Hi Rich, and Welcome to the Forum!

An MRI can often see growth of one's cancer through the thin capsule, but keep in mind that the pathologist samples the entire prostate and looks for microscopic growth into or through the capsule. That said, the descriptor "non-focal" is used when there is more than one ("focal") or more ("multifocal") spot of growth penetrating the capsule. "Non-focal" is, AFAIK, used to describe one or more larger areas or lines of penetration--check with your doc about this.

While it's possible that the radiologist who read your MRI missed this, it is also possible that the "capsule intact" refers to the gross (naked eye) inspection done to identify and label the specimens received by the path lab--that the capsule was attached to the prostate and had not come off/separated in places during the surgical procedure. Check if the paragraph that wording is in is describing the tissue the path lab received from surgery rather than the paragraphs describing the microscopic findings. This is another point you can clarify with your doc.

I believe your final path staging should read pT3a N0, which, on the plus side means that the EPE (extraprostatic extension) was the only "adverse finding," since you said the margins were negative. We can perhaps tell you more if you post the complete report. What was your Gleason score after your biopsy and what was the final score in the report? How many lymph nodes were removed? (That you were "N0" and not "MX" means that at least one node was examined and that all nodes removed were cancer-free, but the full report will have the exact number of nodes removed).

Depending on (1) you final Gleason score, (2) your first post-op PSA test, and (3) perhaps the extent of the EPE, your RP could be the end of your primary treatment.

Continue to treat your body with respect after your procedure, especially with regard to lifting and strenuous activities. Think of your RP as an investment! smile

Wishing you all the best,

Djin
Posted 3/9/2022 2:41 PM (GMT 0)
I hope you're feeling well after your RP. Djin is a master at offering concise pathology explanations. If you provide additional information, Djin will respond. I'd be very interested in hearing how you progress in these coming days and weeks. Take care.
Posted 3/9/2022 4:13 PM (GMT 0)
Intact just means the pathologist received the specimen in one piece with the seminal vesicles attached.

From there they ink the the specimen and slice it so the edges can be examined. When your slices were examined under the microscope, the surgeon had removed enough tissue cancer was not observed to extend beyond the surgical margin, but there was cancer that had extended beyond the gland.
Posted 3/9/2022 4:49 PM (GMT 0)
great comments. Talking to surgeon today. Final gleason was 3+4. Says 2 lymph glands were examined. Seems low. I'll post what the surgeon says.
Posted 3/9/2022 4:58 PM (GMT 0)
My hunch is that your surgeon will be of the opinion that, assuming your post-op PSA is undetectable (less than 0.1), all you need to do it monitor your PSA going forward and that the RP marks the end of your primary treatment for PCa.

Djin
Posted 3/9/2022 9:16 PM (GMT 0)
Djin, you are correct. I just talked to the surgeon. Yes, I was Pt3aNO. it was described as there were some cancer cells on the surface of the prostate they noticed via staining? so they removed all it and surrounding tissue. (didn't affect nerve sparing at all). I guess that was enough for them to have to assign 3a. My risk of recurrence is no more than if the EPE was never there. PSA monitoring is all that is necessary going forward.

Memo to others: I did work myself into a tizzy self diagnosing online after reading the report before having a convo with the Dr. (don't do what i did and save yourself a lot of angst!)
Posted 3/11/2022 2:25 PM (GMT 0)
Rich, I had similar pathology report to yours back in Feb 2009. I had EPE but negative margins. I didn't have any additional treatment since my PSA was undetectable for the first 6 years Last year my PSA reached 0.12 and that is when I did 8 weeks of radiation, unfortunately my PSA is still the same 4 moths after the radiation. My Urologist told me that in 2009 it was normal not to radiate until the PSA becomes detectible. He said if I had the RP today and EPE is found they will radiate immediately as soon as you recover from the surgery.
Posted 3/11/2022 3:11 PM (GMT 0)
Ed, I'm not certain that that a man with a post-RP grade of 3+4 with EPE as the only adverse finding would be advised to have adjuvant RT. If anything, since the publication of three important studies specifically designed to look at adjuvant vs. salvage therapy, the trend is definitely away from adjuvant toward salvage therapy/early salvage therapy. These studies have shown no real advantage to adjuvant over salvage, except perhaps for high-risk men. The main problem with adjuvant therapy is overtreatment.

Many men who are low- or intermediate-risk after RP with an adverse finding never encounter BCR, and for them RT would be unnecessary. And we know that most men with BCR do no go on to metastatic disease, although most want to treat it, which is prudent, of course. Until recently, it was thought that adjuvant therapy had an advantage for non high-risk men with adverse findings, and that overtreatment of many of them was the price needed to be paid.

IMO Rich's doc is advising what is standard of care for his situation

Djin
Posted 3/11/2022 3:44 PM (GMT 0)
"And we know that most men with BCR do not go on to metastatic disease, although most want to treat it, which is prudent, of course."

Djin,
I'm not sure what you mean by that? Why would most men with BCR not eventually go on to metastatic disease?
Posted 3/11/2022 3:58 PM (GMT 0)
Hey Mattam!

Biochemical recurrence after radical prostatectomy: what does it mean? (2018)

"Understanding the natural history of PCa after BCR is pivotal to figure out its meaning. An excellent report of natural history of BCR was given by Johns Hopkins’s researchers. They performed a retrospective review of almost two thousand men that underwent RP for localized PCa who had not received adjuvant hormonal treatment before documentation of metastasis. Patients with good response to radiotherapy after BCR were also excluded. After a mean follow-up of 5.3 years, BCR (PSA ≥0.2ng/mL) was observed in 15% of patients at a median time of 2.3 years and 34% of them developed metastatic disease. The median actuarial time to clinically evident metastasis after PSA elevation was 8 years and it was dependent on GS 8-10, PSA-DT <10 months and time to BCR after RP. The likelyhood of metastatic disease was 37% in 5 years among those men who had presented BCR. Forty four percent of patients with metastatic disease died due to PCa. Actuarial median time to death after development of metastasis was 5 years. Death time was only influenced by time to metastatic disease after RP (25)."

Remember also that Johns Hopkin's originally proposed BCR be set at 0.4 because some patients see a rise in their post-RP PSA that then plateaus.

Not all men with untreated PCa go on to metastatic disease (as we know many men who die of other causes have incidental, indolent PCa when it is looked for). So it stands to reason that there could be local, non-metasatic recurrence after RP (growth of healthy tissue left behind after RP or non-metastatic PCa). Or perhaps time needed for the regrowth to become metastatic is longer than the remaining years of life.

Post Edited (DjinTonic) : 3/11/2022 9:14:13 AM (GMT-7)

Posted 3/11/2022 4:39 PM (GMT 0)
Rich. I might be very worthwhile to get a Decipher test on the post-RP tissue. It may instruct if/when you ever get salvage. Very important.
Posted 3/11/2022 4:39 PM (GMT 0)
Djin!
Thanks. The goal for all of us, after all, is to outlive it.
Posted 5/30/2022 10:34 PM (GMT 0)
What is a decipher test?
Posted 5/30/2022 10:58 PM (GMT 0)
Decipher is a Genomic test--basically they look at the genetics of your tumor and use that to predict the potential of future problems. Your doctors should be able to arrange it and get you more details.
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