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The Good, Bad and Ugly-My post surgery pathology report

bdhilton
Posts: 759
Joined: Jan 2010

It will be 3 weeks tomorrow since my March 3 surgery preformed by William Catalona out of Northwestern in Chicago. I was in the hospital for 2 days and one night at the Avenue Hotel across the street then flew back to Atlanta. No regrets on my decision, outcome or what is to be…

The worse part was the gas pain on the second day in the hospital and I elected to stop all pain medication about 12 hours after surgery except 325mg x2 every 4 hours as I found that the morphine was really not helping…

I did lose a liter+ of blood (but no transfusion) so I have been taking iron (for 2 weeks and tomorrow is my last day). So my biggest complaint outside of the gas pain on day 2 has been the process to have a regular BM (and I am almost there)…

Day 12 after surgery my cath was removed and I had complete bladder control from minute one…

My clinical Grading was Gleason 4+3=7, TB2, palpable nodule on right base/mid…

My post surgery pathology report in summary is: Gleason 4=3=7, negative margins, right Seminal Vesicles was invaded :-(, lymph nodes were all clear… Catalona said if it was his pathology report he would get salvage radiation 90-120 days out from surgery becuase of the Seminal Vesicles was invaded as well as my Urologist down here in Atlanta but this is only a recommendation right now…I will for sure investigate further before any decision plus weight in my 4 (I will not ask for this number as it can be false high according to Walsh), 8, and 12 week PSA into this factor…Not what I wanted to hear but I know my surgeon did as good as a job as humanly possible and the Seminal Vesicles issue was not my surgeon's issue...Hey I have all negative margins...

However (and interestedly enough that Catalona thought this to be a real good news for me), there were no cancer cells in my nerves or blood veins within my prostate with the Perineural Invasion??? I have another consultation tomorrow and will get a deeper understand of my results and what they mean…Time will tell and I hope to keep a positive attitude and right now and as always this has been in God’s hands…

Best to all

tarhoosier
Posts: 189
Joined: Aug 2006

Google SWOG 8794 for a game changing clinical trial for men in your situation. Run by Trump, Thompson and others who are at the top of research in this field. We MUST take this trial seriously. It is in the Journal of the AMA and full text is free. There has also been a later follow up to the JAMA numbers with additional results providing radiation as an important adjunct treatment for T3 disease. This should be the standard of care for such patients as Catalona himself agrees. Great luck!

bdhilton
Posts: 759
Joined: Jan 2010

Thank you I will for sure spend some time reviewing these trials...

randy_in_indy's picture
randy_in_indy
Posts: 493
Joined: Oct 2009

Sorry to hear of the seminal vesicle invasion. I just found on Ask.com that they indicated that is one of the first places to metastisize to from the prostate. Based on my surgeons comments I find it very unsual that it would have metastisized to the seminal vesicles and not be in the peirnueral nerves running through the prostate since that is where the cancer was found in the biopsy. Obviously I will be all ears because I did have perineral invasion but not in the seminal vesicles. This stuff is really tricky it appears...additionally can we really believe all we are told from the path reports...especially after I got two conflicting gleason readings on my biopsy results from one lab to another and even very different volume reads on one of the slides...and after a lengthy discussion with a patholigist they said reading samples is much more subjective than one might think and its really more of an art form to read biopsy samples. Please ask about the 90 to 120 day rest prior to the raditaion option as I was told you need at least 6 months to heal from the surgery prior to any radiation for several reasons - 1. easier to pinpoint the area needed to radiate because after removal of the prostate it needs time to resettle in your body and I think the main reason was any recovery in both incontinence and ED is frozen in place at the time of the first radiation treatment. - that is just what my surgeon team is telling me. Sounds like you are recovering even faster than I did...it's all that mountain climbing that has you in very good shape hence quick recovery...brother is doing the 5 day indian reservation hike down into the Grand Canyon with his two daughters and their friends...he's 55 and worried about keeping up with the 20 something year olds... I think he's back on Thursday. I am telling you one thing...I saw that pic you had up breifly of climbing the face on what appeared to be a rickty ladder up the sheer face...never...ever will I be on that planet! I am sure you will be ready for your July climb.

Randy

bdhilton
Posts: 759
Joined: Jan 2010

Thanks for the thought…My wife refuses (from day one) to give me any sympathy (but I know she worries and cries when she thinks I am not around)…It is good that she wants me strong. She lost both of her parents at an early age to cancer. I am still hopeful that I will beat this beast or at least have another 25+ years… but it will be what it will be…

Yea, Catalona thought it was unusual (but good) that I did not have any tumor cell in my blood veins or nerves in my actual prostate and you are right who the hell knows these doctor do their best but they get stumped all of the time….but I think my spiritual adviser say it the best…logic, statistics, and science all go out the window when you have cancer or other serious health issues as anything can and does happen…Life is a mystery….Like my mom with over 25 years with multiple myeloma and never sick a day of her life(no treatments ever) with this dreaded cancer …she believe (and truly believes) that her diet and faith keeps it at bay…83 and going strong…

Actually Catalona recommended/suggest that I have this radiation 90 day after surgery if it were his pathology report and my urologist said 120 day…I will for sure look at the 6 months or so you are talking about…I am sure I will leave no stone unturned…
Your brother is doing the Grand Canyon at an obviously good time of year as it is hot as Haiti is the late spring and summer…

The rickety ladder you mention is actually a steel cable and the wood you see are resting points every 11 feet or so…It is not what I call climbing or what I did for years but want to give my #3 son the rush of being a few thousand feet up as safe as you are going to be at a few thousand feet up (if the cables were not there it would be a 5.0 climb) …who knows I just might decide to take him on an actual climb the last 400-600 feet…anyway it is a rush…

Again, thanks for your thoughts as others here and it will be what it will be but I have no intention in going “quietly into the night”...I did 5 miles today (4 seperate walks) at my typical hiking speed of 4mph (15 minute miles)just need to add the hills in the weeks to come

Best to all

mrshisname's picture
mrshisname
Posts: 186
Joined: Feb 2010

Randy talks about his rock star surgeon, BD you are the rock star of this group! I have no doubt you will be climbing before long at all. Anyway, I hate it that you are looking at possible radiation treatment, and I would certainly research the time frame and factor in your PSA's, I see patients status post surgery a lot and they usually will have a good healing period before radiation is considered, and as you know time is on your side with this slow-growing cancer (thank goodness).
I read the first part of your post above with great interest, I too lost both of my parents (mom at 64, dad at 78, when I was 23 years old and then 38) to the beast cancer and I think that is what is getting me down right now. Tell your wife if she'd like to converse by email or even phone I'd love to chat with someone in the same moccasins, so to speak. Maria (snooksmama@insightbb.com)

bdhilton
Posts: 759
Joined: Jan 2010

As always, thanks for your positive input and wishes. I have no question that I will be in good shape again and soon. I am up to 5 miles a day (4 walks and at 4mph now).

I saw my Urologist today for my final lesson and solo I might add for my penile injections (plus 5mg Cialis daily-)…Once you get past the sticking a needle in your private it is not bad…Sorry for deviating…

My Doctor told me for once in my life not to “over think” what is going on and have faith (I am extremely analytical) . He said that “believe it or not” we probably got all of the cancer…but to be sure because you are young we want you to have the radiation because of the right Seminal Vesicles…” It will be my decision at the end and I am sure I will go with it if I have 0 PSAs in the next 120 days or a climbing one… I am leaning towards having the radiation done down in South Carolina at the Carolina Regional Cancer Center. I have a coastal home down at Pawley’s Island about 25 miles from this Center and will be able to extend our typical summer coastal stay to another month and right now the idea of the warms sun, daily runs on the beach, fishing and large shrimp at the dock for $3.00 per pound sound good to me…we will see I just might stay in Atlanta and have it done at St Joseph Hospital ….nah…. Seriously time and research will tell but the Carolina Regional Center is looking like a good choice for me right now…

Randy is right that you want to wait as long as possible to have the radiation but my surgeon is saying 90 days and my Urologist is saying 120 days +/-…I will weight this when it is time….

Thanks to all for your support and well wishes…

zakpaga
Posts: 66
Joined: Jan 2010

BD,

Sorry to hear that your seminal vesicle was invaded. But as you are a man of faith, continue to believe that doctors treat but God is the ultimate Healer.

I just got my pathology report with High PIN intraprostactic invasion with carcinoma. When the surgeon came to see me in my hospital bed, the question I asked was " did you spare my erection nerves?" He replied yes. But I still have to be sure. Maybe when I will start taking Viagra, I will know for sure. My Gleason score was downgraded from 4+3 to 3+4, but both sides of the prostate had cancer while the biopsy only showed that the rigth side was invaded.

Let's keep up with the good fight and continue to believe in God.

Victor

bdhilton
Posts: 759
Joined: Jan 2010

I am so happy that your gleason was downgraded as this PC sucks..that is excellent news...Yes my clinical grading showed right only as well...It sounds like with the gleason downgrade and sparing of your nerves you will be back to your old tricks in the coming months...Yes I am a man of faith and have no clue what is in store for me...life is a mystery

Best to all

bdhilton
Posts: 759
Joined: Jan 2010

Exam Date and Time: 3/3/2010 12:00 PM Results Date and Time: 3/8/2010 8:18 PM
Final Diagnosis
A.Lymph Node, Right Pelvic, Excision:
-One Lymph Node, Negative for Metastatic Carcinoma
B.Lymph Node, Left Pelvic, Excision:
-One Lymph Node, Negative for Metastatic Carcinoma
C. Prostate and Seminal Vesicles, Radical Prostatectomy:
-Prostate Adenocarcinoma with Focal Ductal Differentiation, Gleason’s Score 4+3=7, involving both the Right and Left Prostate Lobes
-A tertiary Gleason’s Pattern 5 Component is Present
-Extensive Extra Prostatic Extension is Identified Involving the Right Apex, The Right and Left Mid, And The Right Base
-The Adenocarcinoma Focally Extends To The Inked Margin In The Right mid Prostate (Slides C8 and C9)
-The Adenocarcinoma Invades Into The Right Seminal Vesicle
-The Left Seminal Vesicle Is Free Of Tumor
-The Remaining Surgical Margins Are Free Of Tumor
-Intraductal Spread of Adenocarcinoma is Present (See Notes).
-Extensive Perineural Invasion is Present
No lymph vascular Space is Present
-The Dominant Tumor Nodule is Present in The Right Prostatic Base and Measures 2.2 CM in the Greatest Dimension.
-Additional Tumor Nodules Are Present In The Left Apex, Right Apex, Right and Left Mid Prostates, and The Left base. The Adenocarcinoma is Present In 24 of 34 Submitted Slides And Involves Approximately 18% of the Prostatic Volume.

-High Grade Prostatic Intraepithelial Neoplasia.
Note: The positive surgical margins are in an area of extra prostatice extension. The ductal differentiation is best appreciated in slides C33 and is focal in nature (less than 5% of the total tumor). A PIN4 immunohistochomical stains perform on block C23 supports the diagnosis of intrductal spread of carcinoma. Dr; Ximing Yang has reviewed selected slides for this case and agrees with the above interpretation of margin status and seminal vesicle invasion.

This test was developed and its performance characteristics were determined by the Northwestern Memorial Hospital Immujnohistochemistry Laboratory. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. This tst is used for clinical purposes. It should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1900 (CLIA-00) as qualified to perform high complexity clinical laboratory testing.

The positive Control demonstrates appropriate positive staining. The known tissue negative controls were negative. The non-immune serum control was non-reactive.

Prostatic Cancer Staging Summary:

Tumor Type: Acinar with Focal Ductal Differentiation

Gleason Score
Primary + Secondary: 4+3=7
Tertiary: Pattern 5

Location Main Tumor: Prostatic Base
Location Additional Tumor Nodules: Left Apex, Right Apex, Right Mid, Left Mid, and Left Base

Extraprostatic Extension
Focal (<2 Microscopic FOCI): N/A
Established (Extensive): Present and Extensive

Margins
Apical Margin: Free of Tumor
Bladder and Urethral: Free of Tumor
Other Surgical Margins: Positive, right mid Prostate

Seminal Vesicles: Positive for Carcinoma
Location, If Involved: Right Seminal Vesicles

Perineural Invasion: Present

Lymphatic/Vascular Invasion: Not Identified

Total Lymph Nodes: 2
Number positive: 0
Tumor Volume Approximately 18%
Tumor (T): pT3b
Metastasis (M): pMX
Nodes (N): pN0

randy_in_indy's picture
randy_in_indy
Posts: 493
Joined: Oct 2009

They must of misinformed you of the Perineural invasion as I see it twice for being positive in the report above.... As I thought it was very odd with the 4+3=7 and in both lobes that you would be free of the prostate internal nerves clear of cancer. Just another reason it's always good to get a hard copy of the actual report from every test you get.

BD, What does this mean exactly? "Note: The positive surgical margins are in an area of extra prostatice extension. " I think I also had extraprostatic extension which was discribed to me as only breaking through the internal capsle and not making it out into the Surgical Margins around the prostate...therefore being confined..but within 1mm of breaking through in two places in the prostate.

I was under the impression that "positive margins" are only outside the prostate.

This stuff is maddening!

My Stats:

52 years old
PSA 9/09 7.25
PSA 10/09 6.125
Diagnosis confirmed Oct 27, 2009
8 Needle Biopsy = 5 clear , 3 postive
<20%, 10%, 10%
Gleason Score (3+3) 6 in all positive cores
11/09 Second Opinion on Biopsy slides from Dr. Koch
(4+3) = 7 5%
(3+4) = 7 10%
(3+4) = 7 10%
Endorectol MRI with Coil - Indicated the Palpal tumor was Organ confined
da Vinci 12/29/09 - Dr. Hollensbee & Scott
Post Surgery Pathology:
Prostate size 5 x 4 x 3.5 cm Weight: 27 g
Gleason: Changed to (3+4) = 7
Primary Pattern 3, 80%
Secondary Pattern 4, 18%
Tertiary Pattern 5, 2%
Tumor Quantitation:
Greatest Dimension, Largest tumor focus: 19 mm
Additional Dimension 18 x 15 mm
Location, largest tumor focus: Right posterior quadrant
Multifocality: Yes
Greatest dimension second largest focus 10 mm
Location: second largest focus: Left Posterior quadrant
Extraprostatic extension: Yes
If yes, focal or non-focal: Nonfocal
If yes: location(s) right and left antero-lateral
Seminal vesicle invasion: No
Cancer at surgical margin: No
If no, closest distance with location: less than 1 mm, right posterior quadrant
Apex involvement: No
Bladder involvement: NO
Lymph-vascular invasion: No
Perineural invasion: Yes
Lymph nodes: 9 from right pelvic 0/9 positive
Stage: pT3a, pNo, pMX
All nerves sparred - found two additional pudendal arteries

FIRST PSA TEST 2-11-10 <0.1 NONDETECTABLE

Randy in Indy

bdhilton
Posts: 759
Joined: Jan 2010

I WILL HAVE TO ASK Catalona about that again because that is what I have in my notes (no tumor cells in my blood veins/nerves) But my Urologist told me I was told to not over think this today and I will take this advise (I will be well informed but I will have faith)…

As you know, these pathology reports are subjective and subject to who is doing the study… I know (not believe) I had an extremely qualified research MD studying (plus Yang is studying me on a separate study than Catalona) me and provided a very complete and “realistic” report from his Lab at Northwestern...That is one of beefits of having your treatment at a ressearch hospital...

As far as breaking through the internal capsule and what that means is not clear to me …You would think a breakthrough is a breakthrough…but again I am not qualified but look at your T3a definition ...You seem to be in a good place…be positive and stay there…

Interesting that we were pretty close in our staging: You= pT3a, pNo, pMX and me= pT3b, pNo, pMX
We should talk one of these days…
Best to all

randy_in_indy's picture
randy_in_indy
Posts: 493
Joined: Oct 2009

We should talk. We both had nodgle involvment...we both had extraprostatic extension...the more I am learning and finding out about this beast the luckier I feel. How much more time would my cancer needed to create positive margins and or invade outside the organ....days...weeks....months...One thing is for certain...noone will ever be able to convince me I made the wrong treatment choice...or for that matter to quickly. My freinds Jesse and Maria just saw another surgeon today that indicated 90% of all removed prostates...of which he has done over 1000 via da vinci...end up with a post op pathology that has both more involvement than the biopsy showed and usually a higher grade. 90% seems too high...but another well known teaching Dr. Michael Koch says it's 2/3rds have a increase in grade and volume. I am seriously not trying to scare anyone here that is still contemplating what to do...but just from my own observations of people on here with stats it seems the stats are proving these percentages correct.

Looking at your report again I interpret that the positive margin they indicated occured at the area where there was prostatic extension...which seems only logical and makes sense if it's to escape the organ it would escape it there where it would be the closest to the outside capsle of the organ.... I am guessing my cancer was located in the prostate in an area that had no contact or was close to the seminal vesicle ducts coming into the prostate and thats why I had no invasion. Here I am lucky again...but when I say that I always feel like the other shoe may not have dropped...and only time will tell...in the mean time...in Sonny's word..Every day is a bonus....so live like it!

Off to build a fire in the pit to surprise Annette when she returns from her walk...

Randy in indy

bdhilton
Posts: 759
Joined: Jan 2010

Yes I am working on getting my head wrapped around yet another challenge and the reality is that I am not in the best place and I am also not in the worse place... Anyone’s game (i.e. cancer or survival)
For sure I am on a “slippery slope”….I am doing just about everything I can do from diet and exercise as I say I will not go “gentle into that good night” (see my poem by Dylan Thomas)..but it will be what it will be and worrying about will not make it go away or over analyzing it will make you go crazy from my perspective…I need to bring back my daily mediation….
I am happy that I have a spiritual adviser that I talk with once or twice a month…. Sonny says the same thing with his mantra and I agree…. My wife and I agreed (she initiated) that if we have attitude or a bad day we just need to say “It is a beautiful day today” and realize “every day is a bonus…” Life is a mystery and we just need to make the best of the journey…
Now as far as the surgery we had…I would not take that back it allows us to know exactly where we stand and surgery is the only treatment that gives you that….Surgery allows you to face your “deamons” with this PCa shi&….
But more importantly, I hope that Annette and you have enjoyed that fire tonight…

Best to all

randy_in_indy's picture
randy_in_indy
Posts: 493
Joined: Oct 2009

It was a very nice night for a fire...with a dog in each lap...listening to the waterfall at the other end of the lake in the silence...was very peaceful.

You will beat this...I know it!

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