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Post-RALP Pathology Report

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Posted 5/27/2022 4:38 PM (GMT 0)
Got a copy of my post-RALP pathology report today. It appears to be mostly good news. The lymph nodes are negative for malignancy. Histologic type is Acinar. Grade is Gleason 3+4=7. 35% involvement in prostate. No EPE, no seminal vesicle invasion, and no lymphovascular invasion. What is present is: perineural invasion and bladder neck invasion at the right bladder base - it says a 0.5cm area of Gleason pattern 3 at the margin.

My appointment with the surgeon isn't until a week from now. Any comments on what I'm looking at here?
Posted 5/27/2022 4:57 PM (GMT 0)
Hi AZ. What is your pathological grading in the report? I'm assuming it's pT3a, since there was bladder-neck invasion. It's excellent that your nodes were negative and that there was no seminal vesicle invasion; how many were removed at surgery? You can update your signature with the path-report staging and adverse findings. It's also good that you remained G7 (3+4) and not upgraded.

Perineural Invasion (PNI) found at surgery (but not biopsy) is very common; one study reported it occurs in as many as 82% of men. I wouldn't be too concerned about it. Given your tumor burden of 35%, it's logical that the cancer had been around long enough for it to invade some fine nerves somewhere within the prostate.

Discuss with your doc the implications of the bladder-neck invasion. It's possible that you'll have persistent PSA (1.0 or higher). The extent of the BNI together with your post-op PSA trend will likely influence any adjuvant or future salvage treatment and its timing. Were there any other positive surgical margins noted in the report?

You may want to discuss the value of having a Decipher test done on your RP tissue so you know the risk of your cancer metastasizing (low, average, or high). This results, too, might be helpful in any discussion of adjuvant or future salvage therapy and its timing.

All the best for your post-op PSA report! Keep us posted about your docs' opinions about the report and your follow-up.

Djin
Posted 5/27/2022 5:27 PM (GMT 0)
Thanks for the reply, Djin. Here's the exact info in the report:

Pathologic state classification: (pTNM, AJCC 8th Edition) pT3a, pN0, pMn/a.
3 lymph nodes evaluated, all negative for malignancy.

- Histologic Grade: Grade group 2 (Gleason score 3+4=7)
- Percentage of Pattern 4: 25%
- Percentage of Pattern 5: 0%
- Intraductal Carcinoma: not identified.
- Cribriform glands: not identified.
- Tumor Quantification: Bilateral patchy foci of tumor throughout the tissue sections.
- Estimated percentage of prostate involved by tumor: 35% of specimen sectioned.
- Greatest dimension of dominant nodule: 1.8 cm area.
- Extraprostatic Extension: not identified.
- Urinary bladder neck invasion: Present, right bladder base, (see note below)
- Seminal vesicle invasion: not identified.
- Lymphovascular invasion: not identified.
- Perineural Invasion: present.
- Margin Status: Invasive carcinoma present at margin.
- Linear length of margin(s) involved by carcinoma: 0.5cm (5mm)
- Focality of margin involvement: one focus.
- Margin involved by invasive carcinoma: right bladder neck.
- Regional lymph node status: All regional lymph noes negative for tumor.
- Number of lymph nodes examined: 3
NOTE: The bladder neck sections are composed of prostate tissue. There is a 0.5cm area of Gleason's pattern 3 at the margin.

I realize that no one here is a doctor, but do appreciate any/all feedback. I'm not meeting with the surgeon until late next week.
Posted 5/27/2022 10:24 PM (GMT 0)
Overall, a good report. The bladder neck invasion is a concern--the key question is what your PSA does going forward. You may want to ask if Adjuvant radiation is a good idea--give it a little zap now as a preventive measure.

Keep healing, keep walking. How's the continence and ED going?
Posted 5/27/2022 10:59 PM (GMT 0)
Thanks for the reply, Halbert. I'm trying to stay positive about the report -- the meeting with the doctor isn't until next Thursday and I don't want to read too much in between the lines. Something interesting I read today is that bladder neck involvement coming out of a prostatectomy -- by itself -- may not be a horrible outcome and may only require monitoring. Everything else is pretty much clear. But -- I don't want to play doctor and start reaching conclusions in my head one way or the other.

I'm 10 days post-op at this point, but still have the catheter until next Thursday. No idea about continence and ED until after the rubber snake is finally removed. The doctor wanted me to have the catheter in for a little bit longer due to the fact that I had a TURP procedure just a few months ago. Staying pretty active -- work is all remote and that helps, and my ham shack in the garage is now the most organized it's been in years.
Posted 5/27/2022 10:59 PM (GMT 0)
Hmmm, pattern 3 at bladder margin does not seem warrant additional treatment at this time but getting a second opinion on the pathology slides by Dr. Epstein’s group might be a good idea. Same with the Decipher testing that Djin noted. You probably will sleep better with the some more information and you did all you could at this point to fully understand any risk. All easy to get arranged shortly after surgery.

We all hope for completely negative pathology and move on but then we would have nothing to worry about. Hope your meeting goes well.
Posted 6/2/2022 10:23 PM (GMT 0)
Today was the review of the pathology report with the surgeon (and the removal of the catheter). I'm overjoyed to report that the doctor has declared my PCa almost certainly gone, and extremely unlikely to return. He said "no radiation needed". The pathology was (in his view) entirely negative where it counted -- and he said the "bladder neck involvement" that was seen is because I had a TURP a few months ago, which ground away the original bladder neck and left prostate tissue behind -- which was already known to be cancerous. In other words, the BNI was a bit of a fake-out.

He emphasized his positive outlook, but said that for me everything hinges going forward on the ultra-sensitive PSA tests -- the first of which is three months from now.

On the incontinence side of things, it was a three hour trip to get back home, and although I'm definitely dribbling I was able to hold my urine and had the sense of urgency to go when we got home.

My wife and I are opening a bottle of champagne this evening.
Posted 6/2/2022 10:42 PM (GMT 0)
Great to hear the positive report and for getting that hose out. Enjoy your celebration!
Posted 6/2/2022 11:00 PM (GMT 0)
Great news, so happy for you.
Posted 6/2/2022 11:26 PM (GMT 0)
Also -- the surgeon said he was going to send my old broken parts in for a "Decipher" genomic test so we know even more.
Posted 6/2/2022 11:45 PM (GMT 0)
terrific news.
Question - now that you've had the catheter removed, are you lonesome tonight without your dance partner?

https://www.youtube.com/watch?v=9xvdtx7usnk
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