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Shocking Post Op Pathology Report

AZ Guy
Posts: 9
Joined: Feb 2017


In February I was diagnosed with Gleason 6, 2/12 cores postive one with 5% and one with less than 3% positive for cancer.

My RALP was last Thursday. Yesterday 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.

RobLee's picture
Posts: 264
Joined: Feb 2017

You didn't blow it. Biopsies are random. It just missed the higher grade tumor.

It happens about 1 out of 4 times. My first biopsy missed the tumor entirely... G8(4+4).

Don't blame yourself. You did nothing wrong. Don't let false guilt tear you apart.

Old Salt
Posts: 821
Joined: Aug 2014

Yes, a 'blind' biopsy can miss that much. A comment that is often made is that a biopsy is like a needle in a haystack. 

Please realize that the 12 (or more) stabs in the prostate remove very little tissue. Anyway, looking backwards serves no particular purpose.

Let's hope that your next PSA result will be really low and that no further treatment will be necessary.

VascodaGama's picture
Posts: 3388
Joined: Nov 2010

Your status did not change in the six month you spent investigating. In reality, a typical 12 needles biopsy analysis less than 7% of a normal size prostate (25cc), therefore, missing the cancer is a possibility. Still worse is that the prostate specimen is not totally sliced and investigated fully under the microscope. I recall reading that pathologists just look at important areas such as the margins of incisions, the tissues in areas out of biopsy range and sporadic places in the inner zones. They also analyze the seminal vesicles, nerve bundles and lymph vascular and nodes, all representing about 10% of the all surface area of 4 mm slides. Here you can read details of the procedure instructions given to pathologists.


The clinical stage pT2c refers to a contained case. The only missing information regards the lymph nodes that were not dissected, a common practice in RALP approaches. The PSA will be your marker of success.

 Best wishes for fast and full recovery.


Posts: 7
Joined: Jul 2017

My advice is that if you are waiting to have the surgery, don't postpone it any longer. Get it while the cancer is still encapsulated and save your life. Once it spreads outside the prostate gland, you are in trouble.

Old Salt
Posts: 821
Joined: Aug 2014

AZ Guy already had surgery...

Posts: 7
Joined: Jul 2017

My advice is that if you are waiting to have the surgery, don't postpone it any longer. Get it while the cancer is still encapsulated and save your life. Once it spreads outside the prostate gland, you are in trouble.

Posts: 398
Joined: Mar 2017

What JS said.

I like you was Mr Analytics - I read and I studied and did flip charts ands spreadsheets and god knows what but that on reflection is a coping strategy not a managing one.  The harsh realities always trump expectations - what you have now is a set of hard facts to work with rather than a load of (albeit highly) educated guesses.

Diet, exercise, weight loss, mental health, family and friends, fun! - these are what you need to focus on now, not what happened leading up to all this. Trust me - you will be kept busy making the most out of your new lease of life :)


Posts: 152
Joined: May 2017

You did not blow it, reference all of the comments above. You took decisive action in a reasonable timeframe. I was also upsatged after surgery - it happens often. Just stay focused and relax as best you can. The new reality is not always fun but take s deep breath and move forward.

It's not about the cards we are dealt, it's about how we play the ones we get.

Max Former Hodg...
Posts: 3690
Joined: May 2012

AZ Guy,

My experience was similiar. My biopsy showed only 1 of 12 cores positive, with only 5% involvement in that one.  My surgery was only a few weeks after the biopsy.

The pathology report showed that in fact it was a significant Stage 2 disease.  This is not uncommon, and is a reason I myself could never be at peace with A/S. Men who are at peace with it, may God bless you all.

PCa Staging and imaging overall are primitive and best-guesses.  I tend to err on the side of caution.

Also: I requested the biopsy because of rising PSA every year for 3 years. The rate was not terrible but steady. My GP said there was no reason to get a biopsy, but gave me a referral to a urologist, and she said as soon as she looked at my chart, "Yes, you need a biopsy." Heck, the GP didn't even believe in the annual PSA.  

On the table during the biopsy, the extractor gun attached to the ultrasound probe jammed after removal of core #11.  The doc told me to hold still while she went and got a tech to "fix" the machine.  It was fixed in a couple of minutes and she then took the last core.  The biopsy results were as follows:  1-11, no cancer. The only positive core was #12.  Exercise due diligence.  To doctors, any given patient is a statistical data pack.  Insist on being an individual instead.


hopeful and opt...
Posts: 2335
Joined: Apr 2009

Note that before one makes a treatment decision, it is appropriate to have an image test such as a 3T MRI. This may show if there is extracapsular extension, where lesions may be in the prostate, one lobe or two, and the extensiveness of the lesons in the prostate. There are also other tests than can be done as a follow up to the MRI, such as a fusion biopsy or a pet scan, etc. 

Many times, as happened with AZ guy, there is an active treatment done, and there is a potential or it is found that  the cancer has escaped. Having proper diagnostic tests will be instrumental in making the proper decision for treatment without incurring a treatment that may not be appropriate.

AZ Guy
Posts: 9
Joined: Feb 2017

Thanks for the feedback. I actually did have a T3 MRI done in April with the findings that there was no indication of known cancer. With G6 and little volume at biopsy I never had a bone scan or CT scan. I wonder if those tests should now be done. 

Understand where you're coming from Max. I never really considered Active Surveillance and wanted to take decisive action. 


hopeful and opt...
Posts: 2335
Joined: Apr 2009

The American Urological Association does not recommend a bone scan for those with Gleason under 8.

An MRI shows greater definition than a CT scan.

I wish you the best

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