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A very belated second opinion on slides

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Posted 3/19/2019 11:45 AM (GMT -5)
I had my open RP in 2002 - long before I found this forum and probably long before people were regularly advised to send their biopsy slides out for a second opinion. My pathology report in 2002 showed Gleason 3+4.

These many years later I'm a patient at Dana-Farber. Yesterday I was looking through my D-F portal to check some dates and past test results and stumbled upon an entry I didn't know was there. I now see that in January 2018 while I was going through initial screening for further treatment, D-F received my original biopsy slides and had them read by a Brigham and Women's pathologist who reported.

"The majority of the tumor is Gleason pattern 4 with a smaller component of Gleason pattern 3 also present."

It may have made no difference in outcomes over the years, especially considering differences in standards of care since 2002. But it looks like I was a slam-dunk 4+3 all along not the 3+4 reported by the original pathologist. And based on what we know today I'd probably have been slotted into ART and ADT soon after surgery

It's just a curiosity to me at this point. But it is evidence of why a second opinion on slides is a good idea.
Jim
Posted 3/19/2019 12:47 PM (GMT -5)
When you say "biopsy" slides, were they the slides prior to RP or the slides from prostate tissue removed post-RP? A lot of patients are either upgraded or downgraded from original Gleason grading pre-RP to post-RP. Just wondering which slides you were referring to.
Posted 3/19/2019 1:38 PM (GMT -5)

JayMot said...
When you say "biopsy" slides, were they the slides prior to RP or the slides from prostate tissue removed post-RP? .

Thanks for catching that. I should have said pathology slides - the ones that were done after my surgery.

Jim
Posted 3/19/2019 2:21 PM (GMT -5)
Interesting. The usual recommendation here is to have 2nd opinions of biopsy slides, but to trust the post-op whole gland slides. You may be almost the first guy here to get a second read of their post surgery slides.
Posted 3/19/2019 3:59 PM (GMT -5)
I re-checked my pathology report from 2002 from UMass Medical center and it clearly says Gleason 3+4

The recent pathology report done for Dana-Farber says:

"Note: Select slides were received for review. The majority of the tumor is
Gleason pattern 4 with a smaller component of Gleason pattern 3 also present."

So "select slides" may leave some room for interpretation. Maybe they only received or reviewed the worst slides.

Post Edited (Bohemond) : 3/19/2019 3:03:24 PM (GMT-6)

Posted 3/19/2019 4:06 PM (GMT -5)
“The usual recommendation here is to have 2nd opinions of biopsy slides, but to trust the post-op whole gland slides.“

I have wondered about this many times. Why are pathology reports for the whole gland rarely confirmed? I suppose the idea is that with the small amount of tissue from the biopsy cores there is less tissue for comparison, making the assessment more difficult, and worth another opinion. So does this really mean that with the whole gland, any reasonably trained pathologist can get it right? Maybe that makes sense to me, but maybe it doesn’t.

Surely they don’t section every scrap of the whole prostate and examine the entire gland - that would be thousands of slides. Or maybe they do? If they just take sections at intervals throughout the prostate I wonder what the probability is they may miss significant information?

Despite a much greater sample from the whole prostate, it would still seem to be a very subjective determination.
Posted 3/19/2019 8:19 PM (GMT -5)
Mattam, I don't know how they do it. It's probably not thousands of slides--back in my student days in Embryology, we had slides called "serial cross section" slides of chicken embryos--where they took a whole embryo and sliced it like a tomato (only thinner) and put each slice in a row on the same slide, so you could start at the top and work down looking at the 'whole length' of the critter one slice at a time. I expect they do something similar with a prostate.
Posted 3/19/2019 9:10 PM (GMT -5)
I sent my post-op slides to JH and got the big G7->G9 surprise. Since I had the 4+3 from the biopsy, it did not seem like the need was there early on since it was clear I should do something. In fact, since the post-op pathology was the same, I almost did not get the 2nd opinion but the people/posts on this forum convinced me that it was a good idea. Not so sure I like the results so far.
Posted 3/20/2019 12:27 AM (GMT -5)
My path slide showed 4+5. With my luck, if they were still here to review (seems they were trashed after 7 years), they would come back 5+4.
Posted 3/22/2019 1:37 PM (GMT -5)

Mumbo said...
I sent my post-op slides to JH and got the big G7->G9 surprise.

I went from G7 to G9. But the only number now that matters is <0.10.
Posted 3/23/2019 3:05 PM (GMT -5)
GoBucks - I think we would be a pretty small group that gets that type of 2nd opinion surprise? maybe not? I was really hoping for 3+4 vs 4+3 or worst case 4+4 but really missed the boat with my expectations thus crushed when I got the news from my doctor. I am liking <0.10 as well for the time being but making the next choice has become most difficult now.
Posted 3/23/2019 3:42 PM (GMT -5)
Next choices are never easy for any of us. Since I have bone mets, I'm looking at lifelong ADT. That with the zytiga+prednisone has kept me in the zero club for about 15 months. Hoping to be here on the forum encouraging G9 newbies in 10 years.
Posted 3/24/2019 11:02 AM (GMT -5)
Good luck with your ADT adventure. The constant PSA monitoring is an endless sentence with PCa since there appears to be no "statute of limitations" on recurrence. My wife is 15 years past breast cancer and they stop the oncology craziness at 10 years add figure that something unrelated will kill her.
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