HealingWell
Search Close Search
☰

Post-surgical pathology vs biopsy pathology

Support Forums
>
Prostate Cancer
✚ New Topic ✚ Reply
❬ ❬ Previous Thread |Next Thread ❭ ❭
Posted 7/29/2018 12:58 PM (GMT 0)
A recent post told how the OP’s husband had been diagnosed with a Gleason 9 (4+5) with pathology confirmed by Dr Epstein. The patient subsequently had surgery and the post-surgical pathology was downgraded to 4+3.
I can’t help but wonder how it’s possible that two pathologists, including the renowned Dr Epstein, graded the biopsy samples as Gleason 4+5 and then the pathologist following surgery sees it as 4+3. It’s wonderful news, but how can it be explained? Do the two pathologists who graded the biopsy samples simply say they’re not perfect, that mistakes happen, and that’s that? I know a post-surgery pathology slices and looks at much of the prostate but not all. Could it be that the tumor from which the biopsy sample was taken was not part of the post-pathology?
Posted 7/29/2018 1:16 PM (GMT 0)
The actual quantity of pattern 5 originally detected in the biopsy core turned out to be so small that it could not be found by the pathologist who examines the surgically removed prostate (but probably there is a very small amount of pattern 5 and the biopsy hit it).
I think I read somewhere that 20% of biopsies underestimates the true grade and 16% overestimates it.
Posted 7/29/2018 3:16 PM (GMT 0)
Pre and post pathologies are different games and comparing the two reports isn't apples to apples. The post op pathology is consider the more accurate as you have the whole prostate in front of you and not some random sample. This can change the percentages of what you're looking at. There is also a time difference between biopsy and post-op. Sometimes months which can add a little variation. And pathology isn't the exact science we'd like it to be and even an expert can look at the same sample and change their mind.

Andrew
Posted 7/29/2018 4:49 PM (GMT 0)
pretty common to see an upgrade after surgery but a downgrade is like getting a letter from the IRS saying you paid too much in taxes
Posted 7/29/2018 5:10 PM (GMT 0)
Its all subjective...when things subjective.. the word mistake...is not quite right...wrong would be a better word...ya know...mistake/accident nuances more to a screw up...to be subjectively wrong really does not "fit"(subjective) in pathology it is as variable as pca effect on various folks...

if one is looking for perfection...one has to be perfect themselves (in order to recognize perfection}....and in that case...one wouldn't need to look for it...nor would pca...even exist for one...no Rube Goldberg trap...more a follow one's own eye


anything is possible...as I often tell my wife...when things I say are not perfect...the tiny dna differential twixt the feminine and the masculine...is amazingly powerful in its effect...again follow one's eye...poke holes at will...its one of the benefits of imperfection...as it impersonates such...much..much to one's satisfation...but not to one's wwwwwwholeness
Posted 7/29/2018 7:13 PM (GMT 0)
We are rarely surprised when surgical pathology matches or is worse than biopsy pathology--and yet we assume there is a problem when surgical pathology shows a downgrade. Pathology is a subjective art--which is why we regularly suggest second reads on biopsies. And yet, even the very best at it isn't perfect. (which is I think what logos is saying)
Posted 7/29/2018 7:17 PM (GMT 0)
So in the original post, it was noted that Epstein saw grade 5 cells in the biopsy’s tissue. But there was no grade 5 in the surgical tissue.

So the question is, was Epstein wrong? If not, what happened to the grade 5 cells. We’re they missed, in the surgical pathology?

In a case like this, I’d want to get a second opinion on the surgical pathology.

Good catch hrpnstuf
Posted 7/29/2018 8:06 PM (GMT 0)
I don't think Epstein was wrong. The prostate specimen is step-sectioned at 4-mm intervals of the gland. A small amount of pattern 5 could be contained within one of the 4 mm slices, unseen by the pathologist (also if a second opinion).
The biopsy needle could have hit one of those small pattern 5 spots, and it was seen by Epstein, perhaps it was tertiary pattern 5? (4+3 with tertiary 5 become 4+5 if seen in a needle biopsy).

Prostatic Adenocarcinoma Grading said...

For needle biopsies
The predominant pattern is given first
The second most predominant pattern is given second, e.g. Gleason score 3+4 as long as the second score applies to >5% of the carcinoma
If the tertiary pattern is higher than both of the first two, it becomes the second pattern, regardless of its prevalence, e.g. 3+4 with tertiary 5 becomes 3+5
For prostatectomies
As for needle biopsies except that a high tertiary pattern is reported simply as a tertiary pattern e.g. Gleason score 3+4 with tertiary 5

Posted 7/29/2018 8:15 PM (GMT 0)
Either way, there is cause for optimism in this particular patient...and the proof, as it were, is in the future PSA. At which point the pathology becomes mostly moot--except for the parts that talk about SVI, EPE, and PNI. The gleason of the pathology becomes a topic of discussion but not prognosis.
Posted 7/29/2018 8:15 PM (GMT 0)

Pratoman said...
So in the original post, it was noted that Epstein saw grade 5 cells in the biopsy’s tissue. But there was no grade 5 in the surgical tissue.

So the question is, was Epstein wrong? If not, what happened to the grade 5 cells. We’re they missed, in the surgical pathology?

In a case like this, I’d want to get a second opinion on the surgical pathology.

Good catch hrpnstuf

Actually the surgical path did note tertiary grade 5 @5%. However, I have to assume that the 2 pathologists, including Epstein, who looked at the biopsy sample and called it Gleason 9 must have seen predominant grade 4, followed by grade 5, whereas the surgical pathology showed predominant grade 4, followed by grade 3. No way Epstein is going to mistake grade 3 for grade 5. I have to think then that what Epstein looked at was not taken from the same tumor as the tissue sample that the surgical pathologist looked at.
Posted 7/29/2018 8:49 PM (GMT 0)

halbert said...
Either way, there is cause for optimism in this particular patient...and the proof, as it were, is in the future PSA. At which point the pathology becomes mostly moot--except for the parts that talk about SVI, EPE, and PNI. The gleason of the pathology becomes a topic of discussion but not prognosis.

I agree; there is cause for optimism, and future PSA is what must be looked at going forward, However as noted in the linked article to which Epstein contributed, a grade 5 tertiary finding is a little more than just a "topic for discussion", and may be of prognostic value more than previously thought.

/www.humanpathol.com/article/S0046-8177(16)30346-X/pdf
Posted 7/29/2018 8:55 PM (GMT 0)

Gemlin said...
I don't think Epstein was wrong. The prostate specimen is step-sectioned at 4-mm intervals of the gland. A small amount of pattern 5 could be contained within one of the 4 mm slices, unseen by the pathologist (also if a second opinion).
The biopsy needle could have hit one of those small pattern 5 spots, and it was seen by Epstein, perhaps it was tertiary pattern 5? (4+3 with tertiary 5 become 4+5 if seen in a needle biopsy).

Prostatic Adenocarcinoma Grading said...

For needle biopsies
The predominant pattern is given first
The second most predominant pattern is given second, e.g. Gleason score 3+4 as long as the second score applies to >5% of the carcinoma
If the tertiary pattern is higher than both of the first two, it becomes the second pattern, regardless of its prevalence, e.g. 3+4 with tertiary 5 becomes 3+5
For prostatectomies
As for needle biopsies except that a high tertiary pattern is reported simply as a tertiary pattern e.g. Gleason score 3+4 with tertiary 5

Thanks for that explanation. If I understand you correctly, the biopsy samples probably contained 4+3+5 which was reported as 4+5, and matched the post surgical was 4+3+5.
Posted 7/29/2018 9:08 PM (GMT 0)
The tertiary 5 is new data, and explains it. I think it’s very possible that it’s just a matter of where the needle hit in biopsy. It might have been the secondary pattern in the biopsy but the tertiary pattern in the surgical specimen, when looking at the whole picture.
Posted 7/29/2018 9:14 PM (GMT 0)
As we've said many times, needle biopsy is akin to poking a muffin with a needle and (maybe) hitting a blueberry. PC is typically multifocal-as in there are multiple tumors in the gland. If the biopsy hit the (one) tumor that contained some G5, while the surgical pathology has the opportunity to study the whole gland, it's likely they are both right. (I note my own case, where the biopsy had 3 positive cores, all on one side, while surgical pathology had it in all 4 quadrants, with an upgrade.)

Again, we are never surprised with post surgery when we see an upgrade--but we question the results when they show a downgrade. I see that issue as being more about what is between our ears than what is in the gland.
Posted 7/29/2018 9:51 PM (GMT 0)

halbert said...

Again, we are never surprised with post surgery when we see an upgrade--but we question the results when they show a downgrade. I see that issue as being more about what is between our ears than what is in the gland.

It seems entirely reasonable to question a downgrade and not an upgrade for the reason you point out using the muffin analogy. An upgrade might not be surprising given the amount of tissue being examined after surgery and the multi focal nature of the disease. An upgrade is just as likely a new finding as it is disagreement with previous biopsy pathology. On the other hand, a downgrade from a Gleason 9 to a Gleason 7 is unusual, whereas a downgrade of Gleason 9 to Gleason 8 is probably just difference of opinion. Seems to me that Gleason 9 to Gleason 7 needed more of an explanation, and thanks to Gemlin I have it. Usually when something seems unreasonable there is a logical explanation.
Posted 7/29/2018 11:15 PM (GMT 0)
Interesting topic. All 12 of my cores were 4+3. Pathology was 4+4. Must have been a difference of opinion between the the pathologists rather than sample error. What are the odds of getting 12 G7 cores from a prostate that’s really G8? Very very small.
Posted 7/30/2018 12:10 AM (GMT 0)

hrpufnstuf said...

Gemlin said...
I don't think Epstein was wrong. The prostate specimen is step-sectioned at 4-mm intervals of the gland. A small amount of pattern 5 could be contained within one of the 4 mm slices, unseen by the pathologist (also if a second opinion).
The biopsy needle could have hit one of those small pattern 5 spots, and it was seen by Epstein, perhaps it was tertiary pattern 5? (4+3 with tertiary 5 become 4+5 if seen in a needle biopsy).

Prostatic Adenocarcinoma Grading said...

For needle biopsies
The predominant pattern is given first
The second most predominant pattern is given second, e.g. Gleason score 3+4 as long as the second score applies to >5% of the carcinoma
If the tertiary pattern is higher than both of the first two, it becomes the second pattern, regardless of its prevalence, e.g. 3+4 with tertiary 5 becomes 3+5
For prostatectomies
As for needle biopsies except that a high tertiary pattern is reported simply as a tertiary pattern e.g. Gleason score 3+4 with tertiary 5


Thanks for that explanation. If I understand you correctly, the biopsy samples probably contained 4+3+5 which was reported as 4+5, and matched the post surgical was 4+3+5.

I recall (or I think I recall) one of TA's explanations from about a year ago. The first number is the predominant pattern, and the second number is the "next most serious" pattern, or something like that... So the pattern 5 would take the place of the next most prevalent pattern, which was 3. Or something like that.

In my case, it was simple... everything was grade 4. Well, except for a couple of cores that were 15% 4+3, which I usually never even include. But I've "upgraded" my sig just for this special occasion! smilewinkgrin
Posted 7/30/2018 2:30 AM (GMT 0)
Halberts first post of the thread...first sentence...there is that pesky possum pogo ...not halbert ...the truth he spoke...anybody think I should start a thread on that issue...I didn't think so...so I guess I'll just go along to get along...We are all wired that way...and thus doomed...or as Sartre {name dropping?!)
said "No Exit " sad.. If A new guy shows up...with a tag Jester....
✚ New Topic ✚ Reply