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Shocked at Post Op Pathology Report

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Posted 8/30/2017 4:50 PM (GMT -5)
My RALP was last Thursday. Today was my post-op and the surgeon gave me the report from pathology-

* Now Gleason 4+3
* bilateral disease
* Pathologic staging pT2c
* Right apical margin positive.
* Focal prostate margin positivity, right anterior lobe.
* Negative for extraprostatic extension
* Negative for seminal vesical invasion
* Negative for lymph-vascular invasion
* Positive for perineural invasion
* lymph node sampling not performed (given my low-risk biopsy report)
* dominant tumor nodule 1.2 cm

Can't believe its so much worse than my biopsy pathology in February. I am wondering if I blew it by waiting six months to consider my options and have the surgery. Once I decided to have the surgery I spent the summer by dropping 8 pounds, doing planks and kegels. I thought I was doing everything I could to make the surgery recovery easier.

How does one go from low-volume Gleason 6 to bilateral Gleason 4+3 in six months? Can the biopsy miss that much? I like to think I'm an analytical person and did my due diligence. Even had the biopsy Gleason 6 confirmed at Mass General. Now I'm feeling shocked at these results.
Posted 8/30/2017 4:57 PM (GMT -5)
Sorry to hear that news and I suspect the 6 month delay had no impact, it is a slow growing disease. And it gives me pause. Hang in there. Denis
Posted 8/30/2017 5:07 PM (GMT -5)
Been in that exact situation, see my signature - shock after shock. Biopsies are hit or miss, pun intended. Like Denis said the six month wait most likely made no difference.

Your doc might want you to go for the 'triple play' of ADT and then ART to be extra proactive.
Posted 8/30/2017 5:12 PM (GMT -5)
The standard 12 core biopsy is somewhat random. While unusual, it is possible that the biopsy missed this.

It's a shocker for sure, but still there is every reason to hope that the surgery removed the badness.

Don't second guess the delay, likely it wouldn't have changed the outcome.

What you need to do now is to rest, heal, recover and wait for that first PSA op PSA test. That's the number you really want to see and the number that will prove surgery worked.

Hang in there,
Andrew
Posted 8/30/2017 5:15 PM (GMT -5)
This has nothing to do with your waiting, in all likelihood. about 25-30% of surgical pathology reports result in an upgrade in Gleason score. I was upgraded also from unit lateral to g7 (3+4) bilTERAL

positive margins are what they are, not a result of delay, just the way the prostate was cut out and what the surgeon saw, and didn't see, I think.
Don't beat yourself up and second guess, it is what it is. You may need further treatment, but even if you do, you'll be ok
Posted 8/30/2017 5:45 PM (GMT -5)
Sorry about the path report. What was the tumor volume (%). We are very close in age and PSA. I was surprised to see that I had a lot of cancer ( 20%) in my path report.
Take rest but do walk as much as you can. You will feel a lot better after the Cath comes out. Do take prune juice. Helps in getting that first motion going.
Posted 8/30/2017 5:47 PM (GMT -5)
All 12 of my cores were graded 4+3. When the pathology came back at 4+4 plus focal of 5, I thought it was shocking and improbable. Seems like the pathologists had glaring differences of opinion.

I think you did everything right, but things just didn't turn out as planned. Follow the rest your journey with the same diligence and I also think you'll be okay.
Posted 8/30/2017 6:09 PM (GMT -5)
Sorry about the path report but at least you had the surgery done. With your pre op stats, you could have easily chosen active surveillance. With only small amount of Gleason 6, what prompted you to choose surgery? Had you had an MRI?

I got my catheter out Monday. It's definitely better after that. Walking helps with everything. The work you did this summer will help your recovery for sure.
Posted 8/30/2017 7:04 PM (GMT -5)
Thanks for the responses. After some unpleasant days of recovery its tough to get this news. But we'll just have to deal with it.

ddyss- I don't see volume % in this report, but with a dominant tumor module of 1.2 cm, multiple tumors and a total prostate weight of 22g I would have to suspect its very high.

RickTrin- Given my age, the 20 years of finasteride use (to stop losing hair...this is a wild card) and my desire to be aggressive and deal with it now....I chose surgery. One of the reasons for surgery was to get the full pathology report.
Posted 8/30/2017 7:06 PM (GMT -5)
Oh...and I had an MRI in April....it came back great with "no findings for known carcinoma". So I wouldn't put much faith in the MRI...
Posted 8/30/2017 7:19 PM (GMT -5)
AZ guy, I, also, had a post surgery upgrade...not as much as you (I went from G6 on one side to G3+4 in all 4 quadrants). The key for you is to recuperate from the surgery and see what your PSA is in 3 months. Seriously, 3 months. Your doc may do a PSA at 6 weeks, but it's not definitive till 3 months. In the meantime, walk, eat well, do your kegals, and get back in shape.
Posted 8/30/2017 7:26 PM (GMT -5)
Waiting likely had no effect. What kind of an MRI did you have? You discovered the reason why AS should always have a confirmatory biopsy, preferably mpMRI-targeted or template mapping.

More importantly - what was the size and grade of the margins at the apex and the anterior?
Posted 8/30/2017 8:21 PM (GMT -5)
Tall Allen- The MRI was w/ and wo/ contrast on a 3 Tesla unit:

Findings: The prostate gland measures 3.1x2.3x3.6 cm for an estimated volume of 17 cc. There is evidence of BPH in the central gland. The normally hyperintense peripheral zone is heterogeneous with nonspecific multifocal areas of intermediate to low signal. There is no restricted diffusion or washout type contrast kinetics. No capsular bulging is appreciated. The seminal vesicles are normal in signal. Bladder is not well distended but demonstrates a thickened wall probably related to chronic outflow obstruction. There is no pelvic lymphadenopathy. There is no significant free fluid. Visualized bowel is normal in caliber.

Impression: Patients known malignancy is not identified. No findings suspicious for extracapsular spread or seminal vesicle invasion. No pelvic lymphadenopathy.

I do not see size/grade of the margins at the apex and the anterior on the pathology report.
Posted 8/30/2017 8:33 PM (GMT -5)
You didn't have the kind of MRI that is used to detect high grade cancer for active surveillance. But if you were headed for surgery anyway, you wouldn't need one.

Ask your pathologist for the size and grade at the margin - it might turn out later to be useful.
Posted 8/30/2017 8:55 PM (GMT -5)
My biopsy reported 2% of the biopsy samples were cancer. The prostatectomy specimen was 8% cancer. This is very common. It is just a question of where the biopsy needles happen to intersect. In fact it has been reported that biopsies have 20%+ false *negatives*, simply because the needles just didn't happen to intersect the cancerous tissue.
==========
This is my first post here. I have done a LOT of reading. Age 75 // PSA=6.8 // Pathology found cancer on both sides / 8% of organ was cancer / organ size 29ccs / one 1 mm positive margin // just got an Ultrasensitive PSA ten months after surgery which came out at 0.009 // I suppose I should be worried about this but I really am not // But any input will be welcome especially references to data that may be relevant. Some data I have seen suggests people like me have a 15% probability of BCR in five years. And if BCR-free for five years the likelihood of recurrence drops to very small (Kaplan-Meier curves go nearly flat). But other than this I am very healthy (zero medications for example) so prostate cancer may have more time to work on me than on some others my age! So I do need to be conscientious about it. TIA for any thoughts.
Posted 8/30/2017 9:36 PM (GMT -5)

AZ Guy said...
My RALP was last Thursday. Today was my post-op and the surgeon gave me the report from pathology-

* Now Gleason 4+3
* bilateral disease
* Pathologic staging pT2c
* Right apical margin positive.
* Focal prostate margin positivity, right anterior lobe.
* Negative for extraprostatic extension
* Negative for seminal vesical invasion
* Negative for lymph-vascular invasion
* Positive for perineural invasion
* lymph node sampling not performed (given my low-risk biopsy report)
* dominant tumor nodule 1.2 cm

Can't believe its so much worse than my biopsy pathology in February. I am wondering if I blew it by waiting six months to consider my options and have the surgery. Once I decided to have the surgery I spent the summer by dropping 8 pounds, doing planks and kegels. I thought I was doing everything I could to make the surgery recovery easier.

How does one go from low-volume Gleason 6 to bilateral Gleason 4+3 in six months? Can the biopsy miss that much? I like to think I'm an analytical person and did my due diligence. Even had the biopsy Gleason 6 confirmed at Mass General. Now I'm feeling shocked at these results.

Yes, the biopsy can miss that much and more, not uncommon. Sometimes it shows no cancer in guys who turn out to be hi risk. The needles can not sample every area of the prostate, anything they do hit and show is just mainly blind luck. Main thing is: that report is worse than you thought it would be, but still not too bad at all.

Really, seems to me, it matters not about it being in both lobes or about perineural invasion. ( Y'all correct me if I'm wrong) You would worry more about those things if they showed during the Bx because it might indicate an increased risk of you having EPE, SV or lymph node invasion. But you are negative in all of those very important areas(but LN not sampled?), so any increased risk for for being positive in them doesn't seem to matter a lot.

The main thing is you have gone from a 3 to a 4(4+3=7), which bumps you up from the lowest risk but still not considered high risk. And you have those focal ( are they all focal?) positive margins. But Y'all correct me if I am wrong, I still don't think that constitutes a big bump in risk, knocking you into the hi risk. Some one else will know for sure, better than me.

There is no telling how many years that cancer has been lurking and growing inside you. I doubt that 6 months made much difference, and it probably made no dif on your Gleason score. More likely the Bx needles simply missed the G7. It is a blind shot trying to spear some tiny cells. Easy to miss. Hang in there, Brother!
Posted 8/31/2017 5:12 AM (GMT -5)
Biopsies are not that great at sampling some parts of the prostate, sometimes it's the location of the tumour that causes these surprises. It is very very common for people to go from 3+3 on Bx to 3+4 post surgery. Less common to go to 4+3 post surgery but it does happen. It is unfortunate that you also have some positive margins, if you are 3+3 at the margins that would be a good thing, it would be good to find out.
Posted 8/31/2017 6:47 AM (GMT -5)
Hi AZ Guy - and a very warm welcome from one G4+3 to another. I'm so sorry to hear about the upgrade, but very glad to hear you've taken definitive action and hope that you are recovering well from your surgery. Please know that waiting that extra time would almost certainly have made no difference to your current situation. Don't be hard on yourself, and keep the faith! I hope we will hear positive reports after your first post-op PSA. All the very best, Jaybee&GG
Posted 8/31/2017 7:32 AM (GMT -5)

Pratoman said...
This has nothing to do with your waiting, in all likelihood.....

Don't beat yourself up and second guess, it is what it is. You may need further treatment, but even if you do, you'll be ok

Excellent advise from Prato.

All things considered, you didn't get a terrible report. Being analitical I'm sure you planned for the worst and hoped for the best, and you've done the right things so far.

So not to worry, find out your margin size and location, and cool your jets until that important first post surgery PSA.

Good luck on the next steps of your journey.
Posted 8/31/2017 8:13 AM (GMT -5)
As guy that is quite normal to get a change in your Gleason after surgery. I went from a 7 to a 9 As Garyi says it could have been worse I only waited 4 months after biopsy so your delay didn't make any difference. Like all the guys have said wait for that 3 month psa with the belief that it will be undetectable n you will be done with this d**m disease the rest of your life! And keep walking!!

Larry
Posted 8/31/2017 9:12 AM (GMT -5)

AZ Guy said...
....I chose surgery. One of the reasons for surgery was to get the full pathology report.


Same here, I wanted to know exactly what was growing in and around my prostate which unfortunately dictated further treatment. With a more favorable path report, I might have been finished after RALP. Consider asking your Doc about the Decipher genome test to evaluate your risk category. My test result put me in a higher risk category which confirmed the need for the 'triple play.'
Posted 8/31/2017 10:52 AM (GMT -5)
AZ Guy,

Those Post-op pathology reports can be shocking when they are upgraded. My husband faced the same thing (See signature). Rest assured that there are still lots and lots of options.

Donna
Posted 8/31/2017 11:06 AM (GMT -5)
AZ,

Sorry to hear about your post-op pathology upgrade. I know what that's like -- exactly what it's like.

Do you know if the pathology report mentioned the Gleason score at the positive margins? That might make a difference in how you proceed.
Posted 8/31/2017 11:31 AM (GMT -5)

R-0.009 said...
This is my first post here. I have done a LOT of reading. Age 75 // PSA=6.8 // ... any input will be welcome especially references to data that may be relevant. Some data I have seen suggests people like me have a 15% probability of BCR in five years. And if BCR-free for five years the likelihood of recurrence drops to very small (Kaplan-Meier curves go nearly flat)... TIA for any thoughts.

That statistic holds true for other cancers as well, based on what my wife's hemo-oncologist told us.
He said if she remains in remission for five years that she will likely never experience a relapse.
Posted 9/3/2017 3:53 PM (GMT -5)
I am seeing the surgeon and having the catheter removed Tuesday. At that time we are going to discuss my situation further. Upon learning of my upgrade after pathology last week, I have to admit my mind was spinning while the surgeon was talking about his "burning" on that right side where the margins were. He was making a case - or mitigating- the impact of the positive margins. He seemed optimistic. And I will be in better position to listen.

Does anyone know whether there are mitigating factors for positive margins? The cynic in me is thinking that the surgeon may just be trying to lessen the impact of what is a major disappointment. Let me know if there are any pointed questions you would ask.
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