Surgical Pathology Report

[zj69]

Hi all,

I went for the surgery two weeks ago. I got the pathology report and sharing it with you for the comments and next step.


DIAGNOSIS

1. Soft-Tissue: periprostatic tissue: Mature adipose tissue, no lymph nodes identified. Negative for malignancy



2. Right external iliac artery node: Three reactive lymph nodes, negative for malignancy



3. Right pelvic lymph node: Four reactive lymph nodes, negative for malignancy



4. Left pelvic lymph node: Metastatic adenocarcinoma (diam < 1 mm) in one of six lymph nodes.



5. Prostate and seminal vesicles, weight 28 gram:

- Predominantly right posterior peripheral zone localization of adenocarcinoma, Gleason score 8 (3 + 5) with a high-grade component, comprising 60% of the carcinoma

- Positive for intraductal carcinoma

- Positive for (focal) extraprostatic extension, negative for bladder neck invasion or seminal vesical invasion (pT3a)

- Surgical margins negative for malignancy

- About 9% of the prostate volume involved by carcinoma



COMMENT

Immunostaining performed to exclude neuroendocrine carcinoma component: Both chromogranin A and synaptophysin are negative, while androgen receptor is intense nuclear positive. The basal cell staining (HMWCK) highlights the intraductal carcinoma component.



Procedure: Radical prostatectomy: .

Prostate Size

Prostate Weight (g): 28 g

TUMOR

Histologic Type: Acinar adenocarcinoma

Histologic Grade

Grade Group and Gleason Score: Grade group 4 (Gleason Score 3 + 5 = 8)

Tertiary Pattern 5 (less than 5%) in Overall Gleason Score 7:

Present

Percentage of Pattern 4: 40 %

Percentage of Pattern 5: 20 %

Intraductal Carcinoma (IDC): Present

Cribriform Pattern: Present

Tumor Quantitation: Estimated percentage of prostate involved by tumor: 9 %

Extraprostatic Extension (EPE): Present, focal

Location of Extraprostatic Extension: Right posterior

Urinary Bladder Neck Invasion: Not identified

Seminal Vesicle Invasion: Not identified

Treatment Effect: No known presurgical therapy

Lymphovascular Invasion: Not Identified

Perineural Invasion: Present: .

MARGINS

Margins: Uninvolved by invasive carcinoma

LYMPH NODES

Regional Lymph Nodes:

Number of Lymph Nodes Involved:

Number of Lymph Nodes Involved: 1

Size of Largest Metastatic Deposit (Centimeters):

0.1 cm

Number of Lymph Nodes Examined: 13

PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition)

Primary Tumor (pT): pT3a

Regional Lymph Nodes (pN): pN1

ADDITIONAL FINDINGS

Additional Findings: None identified

SPECIAL STUDIES

Ancillary Studies: NGS prostate


Thanks

[DjinTonic]

Hi zj69. Sorry your serious post-op path report wasn't what you wanted. I would have all slides sent to Dr. J. Epstein at Johns Hopkins for a 2nd opinion. You'll probably be having talks with your doc and consults with a radiation oncologist to discuss the adjuvant therapy that is indicated (RT plus ADT), given the serious Gleason score, EPE+, positive lymph node, and the presence of both intraductal carcinoma and cribriform pattern. IMO it is also concerning that with cancer occupying only 9% of your prostate you had a positive node. Men at very high-risk with adverse findings after RP should consider adjuvant therapy as part and parcel of their primary treatment: RP + RT + ADT.

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Personally, I don't agree with your path report (not that my opinion is worth much), but from what I have read about prostate-cancer pathology and piecing your findings together, we have:

"Percentage of Pattern 4: 40 %
Percentage of Pattern 5: 20 %"

That leaves 40% for Pattern 3.

By my lights your final path should be G9(4+5).

A "Tertiary Pattern" is usually reported if a higher-grade makes up <5% of all the cancer architecture. (BTW, A "tertiary pattern 3" is never reported because it is of no interest.)

However your report says "Gleason score 8 (3 + 5) with a high-grade component, comprising 60% of the carcinoma. Even though the Gleason 5 was not the second-most prevalent pattern, from what I have read, the Gleason 3 should be demoted. You can discuss this with your doc and perhaps the pathologist if you are interested. For me, the percentages of Grades 4 and 5 merit a G9 (4+5) and not a G8 (3+5) with the 4 ignored. In fact, the reports states

"Gleason score 8 (3 + 5) with a high-grade component, comprising 60% of the carcinoma" since grades 4 and 5 total 60%.

The percentage of pattern 3 is of very little significance in your case, and calling it G8 (3+5) leaves the pattern 4 (40% !) out entirely and puts undo significant on the pattern 3.

IMO it would also be incorrect to call it "G8 (3+5) with tertiary pattern 4", since the 4 was well over 5%. (In fact the line for "Tertiary pattern:" is blank in your report.) It may be that pathologists are divided on how to report a result such as yours.

Put another way, pattern 4 was just as prevalent as pattern 3, so G9 (4+5) has the same statistical merit as G8 (3+5), but is much more significant and IMO represents your risk better.

---------------------------------------------

Let us know what you and your docs decide about your adjuvant therapy. I assume you'll be having your first PSA test fairly early. Perhaps an advanced PSMA-PET scan will be discussed to see whether there are other positive nodes or other metastases. (Please let us know the result if you do get a 2nd opinion on your pathology.)

All the best to you! Chin up!

Djin

[zj69]

Thanks, Djin, for your response. So what should I expect? is it curable after POST surgery?

[DjinTonic]

I think adjuvant therapy is routinely done with what is called curable intent. Assuming that any remaining cancer is in the field of radiation, why couldn't it be curative? It's not impossible that there was only positive node and it is now gone. But you should start a list of all your questions to ask at your visits and consultations. It's the nature of the game that each answer could well generate another question or two! You can profit from the healing time that is usually allowed before further therapy to have you consults, do more reading and research, ask more questions, and work out your plan.

I had a final path of G9 (4+5) after my RP; however, the cancer appeared to be prostate-confined and I had no experience with adjuvant therapy and (so far) have had no need for salvage therapy either. You'll get much more insight from other Forum Brothers who have gone through RP+ adjuvant therapy.

Please keep us informed. We are learners, just like you, and profit from everyone else's experience.

Djin

[Duck2]

zj69,

Before making any other decisions, get a reputable second opinion on the pathology. Your PET scan impression and pathology report is kind of unique.

The positive node is on the opposite side of the cancer and the opposite side that was suspicious in the PET impression, which could have been a specimen handling error. (Or maybe I am reading it wrong). 3+5 isn’t very common. Neither is a positive node with only 9% involvement and focal EPE.

Are you curable? You might be cured right now, but your pathology places you are at substantial risk of having some cells somewhere. That’s the purpose of adjuvant RT and ADT. Today unless you have diffuse Mets, they can still cure your with removal or spot RT. Your clean PET scan is a positive and if your first PSA is undetectable that would certainly be a positive.


Relax and heal, you got at least 4 months until any adjuvant treatment would start.

[Rob Lee]

Generally I agree with Djin's assessment that your scoring should be G9 rather than G8, but for treatment purposes, G8 thru G10 are all grouped into the high risk category, with various combinations of PSA and biopsy volumes and grades differentiating between high risk and very high risk. Your stage and grade can be briefly summed up as G9,pT3aN1. The formality of a second opinion is your call, but not absolutely necessary. It is clear that you have "pretty bad" prostate cancer, and anything beyond that is nit picking of minor details. Your mono focal EPE, negative SVI and BNI, and acinar findings are all positively in your favor, as is your smallish to normal prostate size and small tumor load (<10%). On the other hand, Cribriform, IDC and LVI are negative factors. It is good that your pathologist tested CgA to rule out any mutation to NET.

Your treatment will likely be similar to what Duck and I went thru... 12-18 months of ADT and two months of radiation, probably to be administered starting at six months, assuming that you are able to regain sufficient continence for radiation. This is assuming that any further scans, such as a PET, do not find any distant mets, which in my opinion is unlikely. It appears to me that you were hit quickly with a rapidly growing cancer which was caught fairly early and which had just begun to spread. Good luck to you going forward!

[DjinTonic]

Hi RobLee.

"... but for treatment purposes, G8 thru G10 are all grouped into the high risk category"

Actually G8 was given its own Gleason Grade Group, 4 (high risk), and G9-10 another, GGG 5 (very high risk). In many cases treatment recommendations are the same, but not always. For example, a man who is G8 after RP with, say, a single adverse finding such as a focal positive margin may be advised that he can go ahead with adjuvant therapy or hold off on adjuvant (or salvage) until/unless his PSA begins to rise. SOC is usually to advise G9-10 men with even a single adverse finding (e.g., N1, SM+, EPE+, SVI+, or LVI+) to have adjuvant therapy regardless of their post-op PSA (however many choose not to do so).

I was fortunate in being pT2 N0 with negative margins along with my final Geason score of G9 (4+5), and as I mentioned above, have had no further treatment (so far). However, when I asked my uro/surgeon if he would have advised adjuvant RT if I had had just lymphovascular invasion--the invasion of the fine lymph and blood-vessel network within the prostate--he replied "Yes" without hesitation. I'll have to re-ask the question for the same theoretical situation after a G8 path. I have a hunch it would be "adjuvant or wait and see" for a (4+4) and "adjuvant" for the G8's that include a grade 5, (5+3) or (3+5), the last being the least common G8.

Djin

[Rob Lee]

Thanks Djin. I will defer to you as I know your are more up to date on current research and findings. Yes, you were fortunate, besides having the G5 component. In my case, I was a solid G4 throughout. But it was the T3b (escaped into adjacent tissues, specifically SVI) that automatically put me into the adverse pathology category requiring adjuvant therapy.

At the time of my treatment, SOC specified a combination of PSA > 10 and/or T3a/EPE and at least one G4 core to be categorized as high risk, or PSA > 20 and four or more cores having G4 and T3a or b (or some such convoluted combinations) to be categorized as VHR. That may have changed.

BTW zj69 you may note in the lower right corner of my sig that my younger son had T3aN1 adenocarcinoma, but located in the small intestine rather than in the prostate. Similar pathology, but radiation is generally not used within the digestive tract. He had about two feet of small bowel removed and went thru chemo and has had no problems since. The only positive lymph node was removed during surgery and the chemo was intended to kill any cancer cells that might have escaped into the surrounding area. With luck, your case will be similar and the combination of ADT & ART will clean up any cancer cells that may have escaped.

[zj69]

Thanks, everyone for your reply. I want to add that before my surgery at Toronto General Hospital, I went for a PSMA-PET scan, and I got two treatment options: surgery or Radiation. When I talked to my doctor. he told me that I have intermediate-risk and you can get free from it after surgery, so I chose that option. in my PSMA PET scan finding in sep as below.


FINDINGS:
Prostate:
Focus of intense PSMA uptake within the right prostate gland, consistent with the primary malignancy (SUVmax 57, PET image 416).

Lymph nodes:
A few moderately PSMA-avid right inguinal lymph nodes are seen, measuring up to 11 mm in the short axis diameter on the right side with SUVmax of 4.1 (PET image 404). Further small, mildly PSMA-avid lymph nodes are seen in the left groin with SUVmax of up to 2.8 (PET image 410).

Otherwise no concerning PSMA positive lymph nodes above or below the diaphragm identified.

Skeleton:
No concerning focal PSMA uptake of the skeleton.

Incidental fidings:
Relatively stable appearance of previously seen ground-glass opacities/consolidations within the right lower lobe with associated mild tracer uptake, along with mildly PSMA-avid right hilar lymph nodes this likely represents an inflammatory/infectious process.

[DjinTonic]

Docs shouldn't make prediction promises. It's OK to say--if appropriate--"the indications are that your cancer is prostate-confined, however [caveats]. But in your case, the lymph node findings make even this an inappropriate statement.

Note that your "incidental findings" say the hilar lymph nodes are "likely" an inflammatory/infectious process, but the report does not say this with regard to your "mildly [radionuclide-]avid" inguinal nodes. In fact it says "Otherwise no concerning PSMA positive lymph nodes above or below the diaphragm identified"

Before my surgery, my uro/surgeon said that given the lesion locations on my biopsy, he was fairly sure he could spare one neurovascular bundle, but wouldn't know about the other side until the actual surgery (it turned out he was able to spare both). Given my G10 (5+5) biopsy, he was up front when we discussed RP and treatment options, telling me that I could need adjuvant therapy depending on the path results.

Promises are advertising and inducements IMO, and are not ethical.

Djin

[dayglo]

My situation is obviously different, but my Dr put me on ADT+HT for a couple of months before my radiation started. Basically a shot and daily pills to both stop my PCa from growing as well as "starve" it a bit.

[zj69]

Hi,

I got my PSA after RP.

On 2022 Mar 29, your results were 0.02 ug/L.The reference range is 0 - 3.50 ug/L. . This is considered undetectable?



Thanks

[DjinTonic]

Hi,

I got my PSA after RP.

On 2022 Mar 29, your results were 0.02 ug/L.The reference range is 0 - 3.50 ug/L. . This is considered undetectable?

Thanks

It depends on the yardstick you use for "undetectable". Technically, a result is undetectable if there is a < sign in front of a number. For example, <0.02 (with the < sign) would mean that the test can detect only down to 0.02 and no lower and your result was lower. The reference range refers to "normal" values for men with prostates and is often 0-4 µg/L or ng/mL. It does not mean your test can detect to zero. (Unless you can find a result for someone who also had your particular test and has a < sign, you don't know what the lower limit of detection is for your test.)

For purposes of evaluating RP outcomes, the first PSA test is often done with the same test used for men with prostates, in which case <0.1 would be "undetectable" for that test. So with that metric, you could say your PSA was "undetectable" after surgery. However, that test doesn't tell you much about your actual PSA value, which you naturally want to be as low as possible.

Studies have shown that a post-RP nadir of less than 0.03 is good, and less than 0.01 is even better as far as predicting risk for BCR (rise of PSA to 0.2 and climbing). Note that one doesn't necessarily reach a nadir (lowest value) right after surgery. For example, mine occurred at 7 months post op.

Yours is a very good result!

Djin

[zj69]

Thanks, Djin for your detailed reply. I did my test at DynaCare lab in Canada, trying to understand how they wrote the result. I have found the following. But you are right; I have no < sign in my report. Please check If you can give me some more info from this link.

https://www.dynacare.ca/specialpages/secondarynav/find-a-test/nat/psa%C2%A0free-total%C2%A0ratio.aspx?sr=NAT&st=

[DjinTonic]

I though you had the wrong link--that's the PSA FREE/TOTAL RATIO test, which is used for men with prostates to help evaluate their risk for having cancer and need for a biopsy. AFAIK, it's of no use after surgery. However, I did a quick search in the catalog there and I don't see either a PSA or ultrasensitive PSA test. I'm confused by their website.

Does the result you were given show both a PSA value and the PSA Free to Total Ratio? If you see a number followed by µg/L or ng/mL, it's a PSA value. If you're in doubt or want to know how low your test goes (its lower limit of detection), I would give the lab a call.

BTW, Labcorp does operate in some parts of Canada, and their ultrasensitive PSA test goes down to 0.006 (i.e., it's "undetectable" is <0.006).

Make sure you are looking at an actual lab printout (or web portal) and not a summary or value transcribed by your doctor or a nurse: there could be a transcription error; for example, a < sign might have been omitted.

Djin

[zj69]

Hi Dijin, I went for the test again with a different