Questions about Pathology Report

Timon

In December 2010 my PSA was 5.55; a subsequent biopsy revealed 10 of 12 positive cores with a Gleason of 8. Since I was 62 years old and since the bone scans etc. were negative I opted for the robotic prostatectomy in March 2011.

The first post-op PSA, July, 2011, was 0.0 (the urologist and I were both quite pleased); in March, 2012 the reading was 0.12 (and he told me not to worry because that could be attributed to lab error and in any case was insignificant); but, in October 2012 it was 0.22 (and he advised to "observe for now" and retest in 6 months.)

I recently obtained a copy of the surgical pathology report about which I have some questions:
1. The prostate weighed 28 grams and its measurements were 4.8 x 4.0 x 3.0 cm.
What is the significance of the weight and size?
2. "Invasive tumor involves approximately 50% of prostate. Tumor is multifocal, bilateral, and present from apex to base. It involves up to 2.8 cm of confluent prostate tissue and involves 10 of 19 tissue blocks of prostate.”
Does that indicate an aggressive form of cancer?
3. “Margins involved by invasive carcinoma, multifocal, right and left posterior lobe. Tumor also comes multifocally within 0.5 mm of the margin.”
Does “margins involved” mean the same as “positive margins” in other words, that some cancer may have been left behind? Or is that qualified by the second sentence which seems to say that the tumor comes “within 0.5 mm of the margin.”
4. Lymph Vascular Invasion and Perineural Invasion was said to be “Present, multifocal.” And the report also stated, “Tumor is focally present in periprostatic adipose tissue at base of prostate and is extensively present within lymphatic and vascular channels in extraprostatic adipose tissue.”
What’s the difference between “focally present” and “extensively present” and do these observations also indicate an aggressive cancer which may still remain somewhere in my body?
5. The cancer was staged as pT3a, pN0 with the notation that 8 lymph nodes were examined and "no regional lymph node metastasis was observed." Is there a standard number of lymph nodes that are examined before the pN0 stage is "awarded"?
And with regard to the seminal vesicles it was noted, “Seminal vesical tissue is mostly separated from the prostate secondary to surgical excision. Even so, the entire base of the prostate in area of seminal vesicles is submitted without definite involvement of a scant amount of seminal vesicle tissue present... Also sampling of separate fragments of seminal vesicle tissue ... are negative for malignancy.”
In another part of the report there was a statement: “Seminal Vesicle Invasion: Not identified.”
What’s the significance, if any, of the terms “Not identified” as opposed to “negative for malignancy”?
As noted above, while the post-op PSA's remain relatively low, the last two tests showed an increase in the PSA; given the pathology report, should I be concerned? In another thread, I was advised to request PSA testing sooner rather than later and to research options. I've done a lot of research but received a lot of contradictory information and every time I start the research I become anxious. Before I ask the urologist for another appointment, a sooner PSA, and a discussion of options, I'd like to figure out this pathology report so I can communicate my concerns. Any help would be greatly appreciated. Also, I still remain severely incontinent since the operation in March 2011 so that may also limit future treatment options, right?

hopeful and optimistic

My lay person opinion


A medical oncologist is the best qualified physician to manage your case, get the best most experienced you can afford....time to switch from the urologist.

In my opinion, there can be specks of cancer that were outside the prostate. PSA tests after surgery is used as an indicator to see if the cancer has spread beyond the prostate.Generally, a PSA score of 0.2 indicates recurrent cancer.It now time for a retest.

A gleason 4+4=8 indicates aggressive cancer.

You had a small sized prostate. The cancer in your prostate was extensive. There was positive margins, and extensively present within lymphatic and vascular channels in extraprostatic adipose tissue. No regional lymph node metastasis was observed...generally a sampling of the lymph nodes are taken( I don't know if this varies from one institution to another, or is somewhat standard). Seminal Vesicle Invasion: Not identified.

"Also, I still remain severely incontinent since the operation in March 2011 so that may also limit future treatment options, right?"

Since having more than one type treatment can compound negative side effects, this needs to be taken into consideration.....but the bottom line is that you, if your PSA remains at the level it is at... need to be treated to stop metalizes.

hopeful and optimistic

.

.

tarhoosier

Pathology
Timon:
Your surgeon should answer these questions. I can make an attempt to give some information, though the surgeon who saw and removed the tissue has much more information and experience.

1. Size and weight: Your prostate as removed was within the normal range.
2. You had a large volume of tumor. This confirms the biopsy report which found tumor in nearly all of the 12 sections sampled. A larger volume of tumor is a negative prognostic factor. This does not mean that the tumor itself was aggressive. Gleason score is a measure of cancer cell de-differentiation, or, if you wish, aggressiveness.
{I do not see any Gleason grading of your surgical sample. This is a major omission.}
3. I read this as meaning that there were multiple margins involved, and where not involved the tumor was close to the margin of the excised tissue.
4. Lympho-vascular invasion refers to cancer cells found in the blood channels and lymph channels in the removed tissue. This is a negative prognostic factor. Negative in this case means it suggests cancer cells distributed elsewhere in the body. Multi focal means found in numerous locations. Such cancer cells were also found in the fatty (adipose) tissue that is just outside the gland proper. The surgeon removes nearby tissue along with the gland and this is what the path report refers to. Again, aggression is not an element of this finding. The pathologist only reports what he sees and finds, he does not make predictions or subjective comments.
5. pT3a (the p means pathology after removal) means that there was cancerous cells just at the outer edge of the gland and in nearby tissue, as mentioned above. The surgeon may take no nodes or dozens. Eight is a common number. That the pathologist does not see cancer cells in the nodes by staining and examination with microscope does not mean that they are not there, only that he does not find them with his techniques.
Your seminal vesicles appear to have been fragmented at or after removal, which is not unusual. "Not identified" appears to mean that there was not sufficient clear SV tissue to enable the pathologist to make a finding.

Your missing Gleason grading is the major omission here. Your extent of tumor, pathologic findings, and post surgical psa strongly suggest that your Gleason is 4 or 5, as suggested in the biopsy.
You need to address the continence issue as soon as possible, as I know you wish to do. Who would not? In the meantime consider an appointment with a medical oncologist who provides direction for patients without direct treatment. Your urologist is out of the picture now, as far as cancer treatment goes. If you are comfortable with him/her for your continence treatment then you may continue, or seek professional help elsewhere.
I agree with the doctor that with the pre and post surgical findings that a year with no to little psa rise is about the best one could have asked.

Timon

tarhoosier said:

Pathology
Timon:
Your surgeon should answer these questions. I can make an attempt to give some information, though the surgeon who saw and removed the tissue has much more information and experience.

1. Size and weight: Your prostate as removed was within the normal range.
2. You had a large volume of tumor. This confirms the biopsy report which found tumor in nearly all of the 12 sections sampled. A larger volume of tumor is a negative prognostic factor. This does not mean that the tumor itself was aggressive. Gleason score is a measure of cancer cell de-differentiation, or, if you wish, aggressiveness.
{I do not see any Gleason grading of your surgical sample. This is a major omission.}
3. I read this as meaning that there were multiple margins involved, and where not involved the tumor was close to the margin of the excised tissue.
4. Lympho-vascular invasion refers to cancer cells found in the blood channels and lymph channels in the removed tissue. This is a negative prognostic factor. Negative in this case means it suggests cancer cells distributed elsewhere in the body. Multi focal means found in numerous locations. Such cancer cells were also found in the fatty (adipose) tissue that is just outside the gland proper. The surgeon removes nearby tissue along with the gland and this is what the path report refers to. Again, aggression is not an element of this finding. The pathologist only reports what he sees and finds, he does not make predictions or subjective comments.
5. pT3a (the p means pathology after removal) means that there was cancerous cells just at the outer edge of the gland and in nearby tissue, as mentioned above. The surgeon may take no nodes or dozens. Eight is a common number. That the pathologist does not see cancer cells in the nodes by staining and examination with microscope does not mean that they are not there, only that he does not find them with his techniques.
Your seminal vesicles appear to have been fragmented at or after removal, which is not unusual. "Not identified" appears to mean that there was not sufficient clear SV tissue to enable the pathologist to make a finding.

Your missing Gleason grading is the major omission here. Your extent of tumor, pathologic findings, and post surgical psa strongly suggest that your Gleason is 4 or 5, as suggested in the biopsy.
You need to address the continence issue as soon as possible, as I know you wish to do. Who would not? In the meantime consider an appointment with a medical oncologist who provides direction for patients without direct treatment. Your urologist is out of the picture now, as far as cancer treatment goes. If you are comfortable with him/her for your continence treatment then you may continue, or seek professional help elsewhere.
I agree with the doctor that with the pre and post surgical findings that a year with no to little psa rise is about the best one could have asked.

Thanks
Thanks for the translation! The post surgery Gleason was 4+3=7.

I wonder why the urologist wants me to do another PSA in April instead of referring me to an oncologist now? Is time of the essence at this point?

I'll call him and get another appt. ASAP.

Again. thanks for the insights!

Timon

VascodaGama

Timon said:

Thanks
Thanks for the translation! The post surgery Gleason was 4+3=7.

I wonder why the urologist wants me to do another PSA in April instead of referring me to an oncologist now? Is time of the essence at this point?

I'll call him and get another appt. ASAP.

Again. thanks for the insights!

Timon

PSADT at 6 month
Timon,

I think that your questions in regards to the path report are to get an opinion on the aggressivity of your cancer. You want to know if it is proper to wait 6 months as your doctor instructed.
In my opinion recurrence is apparent through the increase of your PSA and its PSADT, such correlates with the path report contents that indicate extra capsular extensions. Being a Gs8 places you in the high risk for spread so that you do not need more information to proceed with preparations for a salvage treatment. You should now concentrate in finding all possible ways to get a grip on the progress of the disease.

The reported Negative lymph nodes could mean that the spread is still localized and that IMRT could be successful in “killing” the localized spread. Usually the protocol is to irradiate the prostate bed and regional lymph nodes (iliac). You could also choose the combi HT+RT but the hormonal component would mask the success of the radiation because the PSA marker would be attributed to the HT attack.

In my case of SRT, I had RT alone so that the marker of progress was "real". Latter, I followed with HT, once recurrence became again apparent, by the periodical PSA results.

At the moment you could investigate on newer ways of image studies to pinpoint the location of the cancer (with contrast agents C11 or F18). You could also investigate about the “quality” of the RT facilities closer to you and their medical team, while waiting for the next PSA (in 2 or 3 month).
Unfortunately a Gleason pattern of 4 is not an indolent type of cell so that it wouldn't provide you with the possibility of a Watchful Waiting modality.

Hope for the best.

VG

tarhoosier

Timon said:

Thanks
Thanks for the translation! The post surgery Gleason was 4+3=7.

I wonder why the urologist wants me to do another PSA in April instead of referring me to an oncologist now? Is time of the essence at this point?

I'll call him and get another appt. ASAP.

Again. thanks for the insights!

Timon

Now?
Timon:
I would not wait for the urologist to make a recommendation and referral in some months time. I would take charge of my own affairs starting today. You are obviously concerned and interested in educating yourself. Ask here, at your local support group for Prostate Cancer, or elsewhere for the best medical oncologist you can find and afford and go there. I think you will discover that controlling your own treatment will provide you with peace of mind. For me it made much of the anxiety melt away.
I believe that time is more essential for you than it is for your urologist, if that answers your question.

Timon

VascodaGama said:

PSADT at 6 month
Timon,

I think that your questions in regards to the path report are to get an opinion on the aggressivity of your cancer. You want to know if it is proper to wait 6 months as your doctor instructed.
In my opinion recurrence is apparent through the increase of your PSA and its PSADT, such correlates with the path report contents that indicate extra capsular extensions. Being a Gs8 places you in the high risk for spread so that you do not need more information to proceed with preparations for a salvage treatment. You should now concentrate in finding all possible ways to get a grip on the progress of the disease.

The reported Negative lymph nodes could mean that the spread is still localized and that IMRT could be successful in “killing” the localized spread. Usually the protocol is to irradiate the prostate bed and regional lymph nodes (iliac). You could also choose the combi HT+RT but the hormonal component would mask the success of the radiation because the PSA marker would be attributed to the HT attack.

In my case of SRT, I had RT alone so that the marker of progress was "real". Latter, I followed with HT, once recurrence became again apparent, by the periodical PSA results.

At the moment you could investigate on newer ways of image studies to pinpoint the location of the cancer (with contrast agents C11 or F18). You could also investigate about the “quality” of the RT facilities closer to you and their medical team, while waiting for the next PSA (in 2 or 3 month).
Unfortunately a Gleason pattern of 4 is not an indolent type of cell so that it wouldn't provide you with the possibility of a Watchful Waiting modality.

Hope for the best.

VG

Thanks again...
Thanks again for the insights and information. I will heed your advice, and that of Tarhoosier and keep you all updated should conditions warrant. Thanks again and best wishes to you fellows.