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  • #1

    my pathology report

    Hello Again I recently had RP surgery and this is my path report:

    A. PROCEDURE: RADICAL PROSTATECTOMY AND PELVIC LYMPH NODE DISSECTION. Run: 07/28/22 1231 LIS Specimen Inquiry Run User: INTERFACE DIAGNOSIS (Continued) B. PROSTATE WEIGHT: 53 GRAMS. C. HISTOLOGIC TYPE: ACINAR ADENOCARCINOMA. D. HISTOLOGIC GRADE: GRADE GROUP 3 (GLEASON SCORE 4+3=7). i. MINOR TERTIARY PATTERN: 5 (< 5%). E. INTRADUCTAL CARCINOMA (IDC): NOT IDENTIFIED. F. CRIBRIFORM GLANDS: PRESENT. G. TREATMENT EFFECT: NO KNOWN PRESURGICAL THERAPY. H. TUMOR QUANTIFICATION: 51-60% (ESTIMATED PERCENTAGE OF PROSTATE INVOLVED BY TUMOR). I. GREATEST DIMENSION OF DOMINANT NODULE: 1.3 CM, PRESENT ON THE LEFT SIDE. J. EXTRAPROSTATIC EXTENSION (EPE): PRESENT, FOCAL. K. URINARY BLADDER NECK INVASION: NOT IDENTIFIED. L. SEMINAL VESICLE INVASION: NOT IDENTIFIED. M. LYMPHOVASCULAR INVASION: ABSENT. N. PERINEURAL INVASION: PRESENT. O. MARGIN STATUS: INVASIVE CARCINOMA PRESENT AT MARGIN. i. MAXIMUM LINEAR LENGTH OF MARGIN INVOLVED (2 MM), MULTIFOCAL, INVOLVING THE LEFT POSTEROLATERAL IN THREE FOCI, EACH OF WHICH MEASURES 2 MM, GLEASON PATTERN PRESENT AT MARGIN, GLEASON GRADE PATTERN 4. P. NUMBER OF LYMPH NODES EXAMINED: FIVE LYMPH NODES, NO EVIDENCE OF METASTATIC CARCINOMA AS CONFIRMED BY NEGATIVE IMMUNOHISTOCHEMICAL STAINS FOR CYTOKERATIN AE1/AE3 (THREE LYMPH NODES WITHIN THE RIGHT PELVIC DISSECTION NEGATIVE FOR METASTATIC CARCINOMA; TWO LYMPH NODES WITHIN THE LEFT PELVIC LYMPH NODE DISSECTION, NEGATIVE FOR METASTATIC CARCINOMA) (0/5). Q. DISTANT METASTASIS: NOT APPLICABLE. R. PATHOLOGIC STAGE CLASSIFICATION (AJCC 8TH EDITION STAGING): pT3a pN0.

    My psa at surgery was 9.3.
    I meet with the surgeon next week, any advice would be greatly appreciated.


    Tags: None
  • #2
    Hi George and Welcome to the Forum. I'll be happy to add my 2 cents, but I suggest you discuss anything of concern with your docs. Remember: we are not doctors!

    Here are the negative findings, IMO:

    1) The pT3a path staging means extraprostatic extension (EPE) was present, as is noted. It was described as "focal", which means the cancer grew through the thin prostate capsule at one small spot only, which is much better than more extensive EPE, which is usually described as "multifocal" or even "non focal" if even more extensive. Note that this local spread is not the same as metastasis.

    2) Your Gleason Score was 4+3=7, which would be the Unfavorable Intermediate risk group. However Gleason Grade 5 was present, even if it accounted for less than 5% of your total tumor burden. The tumor burden itself was estimated as 51-60% or your prostate, which is fairly large. The presence of grade 5, even though relatively small, bumps up your risk for recurrence and put you in the High Risk group. You can ask your docs, but I think the tertiary 5 bumps you up to the approximate risk equivalent of a G8 (4+4).

    3) There were also three spots that showed positive surgical margins, which is another adverse finding. The margins at these points were small (2 mm), which is good; however the Gleason score at the margins was grade 4 rather than the more favorable grade 3.

    I'm thinking that the Gleason score of your biopsy was probably either 3+3 or 3+4 since your surgeon removed only 5 lymph nodes (I would have expected a higher number if you had gone into surgery with a 4+3 or higher biopsy). However, all 5 nodes were all negative for cancer, which is good!

    4) Cribriform glands were present, which is an adverse architectural feature of the prostate cells that is a another risk factor for recurrence. On the plus side, you had no seminal vesicle invasion, bladder neck invasion, or lymphovascular invasion.
    I believe much hinges on your early post-RP PSA values: If you are at or above 0.1, termed "persistent PSA," I believe you'll be advised to have adjuvant RT after a healing period. if it is "undetectable" (i.e., <0.1) you'll be in the same "wait-and-monitor-your-PSA position" most of us are in following surgery: if your PSA rises at any time in the future you'll be advised to have salvage therapy.

    I would speak to your docs about having a Decipher genomic test done on your removed tissue. This test examines the RNA of your cancer and gives you your risk category (low, intermediate, or high) for developing metastases within 5 years. Assuming your post-op PSA is undetectable (<0.1), the Decipher results can help you and your docs decide at what PSA value you should seek further treatment if your PSA does start to rise. The "official" PSA level for treatment is 0.2 and rising; however, with your adverse path findings and, perhaps, Decipher score, you may be advised to have RT at a lower value. Given your path report, the Decipher test should be covered by your insurance.

    Did you have a bone scan in your diagnostic workup? If your biopsy grade was G6 (3+3) or G7 (3+4) and you did not have one, your doc may suggest one, given the Gleason upgrade.

    I'm sure you were hoping for a better report, but it is indeed possible that your PSA will remain undetectable and you won't have to have any further treatment in the future. Please keep us posted with your progress.

    I wish you all the best,

    Djin
    Last edited by DjinTonic; 07-31-2022, 05:59 AM.
    69 yr at diagnosis, BPH x 20 yr, 9 (!) neg. biopsies, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on right + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule neg. for PCa
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma
    5% of prostate (4.5 x 5 x 4 cm, 64 g) involved
    Dry; ED OK with sildenafil
    11-10-17 Decipher score: 0.37, Low Risk:
    5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%    		 9-16-17 (5 wk) PSA <0.1
    (3 m ) 0.010
    (6 m ) 0.009
    (9 m ) 0.007 (nadir)
    (1 yr.) 0.018 (?)
    (13 m) 0.013 (retest)
    (15 m) 0.012
    (18 m) 0.015
    (21 m) 0.015
    (2 yr. ) 0.016
    (28 m) 0.015
    (34 m) <0.014
    (40 m) 0.037 (?)
    (43 m) 0.020
    (46 m) 0.018
    (52 m) 0.023
    (5 yr) 0.038
    (63 m) 0.036
    (66 m) 0.049

    Comment

    • #3
      Hello George,

      A few comments.

      Given your pathology it is statistically unlikely the surgery resulted in a cure of your prostate cancer and at some time in the future you will need more treatment. The Decipher test provides a genomic score on the aggressiveness of the cancer to assist you on treatment decisions with your doctor. If you insurance will not cover the test, the company may provide a substantially discounted price.

      My surgery was at Cleveland Clinic, but Cleveland is not a local hospital for me. I find being followed by Cleveland and having the doctors I want if I need further treatment reassuring because I want the cutting edge stuff you will see in the videos if I need it. Please take the time to watch both because I believe they will help you going forward.

      https://youtu.be/81iAzYV39Gw


      https://youtu.be/Q2joD360_pI











      Last edited by Duck2; 07-31-2022, 10:04 AM.
      YOB 1957

      DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM &amp;lt;5%, Right side negative.

      3/6/19. Post surgery Pathology Report - Grade Group 4 Intraductal Carcinoma
      T3aNO, <1 mm non focal EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.
      7 Nodes, SV, SM, PNI, and BNI were negative.
      LVI and Cribriform pattern present.
      Decipher .86 High Risk.

      Post Surgery PSA
      3/25/19 .03. (25 days)
      4/25/19. <.03. (2 months)
      5/25/19 <.02 (3 month)
      5/20/22. < .02 (39 months). T=37
      11/7/22. <.02 (45 months) T=54

      3 Part Modality Treatment Completed

      2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery his #41st in US.
      ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
      ADT - 5/19- 5/21 Eligard and Casodex.


      3 Part Modality Treatment Completed

      2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery #41 in US.
      ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
      ADT - 5/19- 5/21 Eligard and Casodex.

      ​

      Comment

      • #4
        Hopefully your six-week PSA is a big zero, but if it is, still get getting tested using uPSA as often as your insurance would pay for it... Such every four or six months for the next 90 years.
        BD: 1959 PSA 4.9 11/2012 (no symptoms)
        Biopsy 12/2012 Negative
        PSA 5.9 05/2013 (still no symptoms)
        Biopsy 6/2013 3+4 (thank goodness for PSA tests)
        1 core positive (upper left), 1 suspicious (lower left) out of 12
        DRE: bump right side T1c; PCA-III = 20 (normala)

        Da Vinci 7/18/2013:
        Total prostatectomy with seminal vesicles (S13-6085, 1-29, 7/18/13, 29 H&E and 1 paraffin block)
        Invasive carcinoma involves left lobe of prostate only, extends from left apex to posterior mid region of left lobe Gleason 7/10 (4+3); G4 tumor comprises 75% of invasive carcinoma present
        Estimated total volume of carcinoma in entire prostate gland: 10%
        TNM: T2b NX MX (Stage IIA)

        PSA History:
        8/13 11/13 2/14 8/14 2/15 8/15 3/16, 8/16, 3/17,9/17,4/18, 9/18 PSA "undetectable" (PSA <.1)

        March '19 = 0.1
        April '19 = 0.10 <-- switched to uPSA tests
        June '19 = 0.10
        Sept '19 = 0.10
        Dec '19 = 0.09
        Jan '20 = 0.13
        May '20 = 0.2 <- standard test by mistake
        Jun '20 = 0.11 <- back to uPSA test
        Aug '20 = 0.16
        Jan '21 = 0.23
        Feb '21 =0.20
        Mar '21 - started ADT/HT, radiation scheduled
        Jun '21 Eight Weeks Radiation @MSKCC
        Jul '21 <.05 (T-Level 0)
        Feb '22 <.05 (T-Level back to normal)
        Aug '22 <.05 (T-Level still normal)

        Comment

        • #5
          Thank you Gentleman for your input, it certainly helps me on what questions to ask the surgeon. I was told less than 5% grade 5 does not add to the overall gleason score, only if greater than 5%. The surgeon is going to seek the opinion of a radiologist on treatment. It does appear a lot will depend on my psa test in September.

          Is it common to have weight loss after surgery? I weighed 239lbs before surgery and down to 224lbs 3 weeks after surgery.

          Thanks for your help.

          Comment

          • #6
            George,

            Not answering your question, but will make the note that losing weight around your belly generally helps you with incontinence.
            Age Dx: 57
            PCa History: Father, Grandfathers, Uncles
            Oct16 Bx: Gleason 4+3 Grade Group 3 w/PNI, LB: 4+3 (60% pattern 4), RA: 3+3, RLM: 3+3, RLA: 3+3
            Jan17 RALP - Pathology = pT3a; Gleason 4+3; Weight: 42g - Dr. Grant Taylor
            Jun19 AMS800 installed, Jul19 activated - Dr. David Rapp
            Sep22 AMS800 failed. Scheduling a replacement if possible.
            PSA_TESTS: Apr16-5.10, Jul16-4.70, Aug16-5.13, Mar17<0.01, Jul17<0.01, Oct17<0.01, Jan18<0.01, May18<0.01, Nov18<0.01, Jan19<0.01, Jun19<0.02, Nov20<0.10, May21<0.10, Apr22<0.10, Sep22<0.10​

            Comment

            • #7
              Thanks MJR didn't mean to put anyone on the spot with weight loss. Common sense should tell me some weight loss would be expected as I'm just over 3 weeks from surgery and my appetite is just now starting to come back. Sometimes reassurance is needed as your mind tends to run away with all kinds of thoughts.

              Comment

              • #8
                Originally posted by George View Post
                Thank you Gentleman for your input, it certainly helps me on what questions to ask the surgeon. I was told less than 5% grade 5 does not add to the overall gleason score, only if greater than 5%. The surgeon is going to seek the opinion of a radiologist on treatment. It does appear a lot will depend on my psa test in September.

                Is it common to have weight loss after surgery? I weighed 239lbs before surgery and down to 224lbs 3 weeks after surgery.

                Thanks for your help.
                Hi George.

                You are correct that, technically speaking, when Gleason grade 5 (or 4) makes up less than 5% of the estimated amount of cancer you have in your prostate, the Gleason score remains the same and that grade is reported as a "tertiary" grade along with the most common (primary) and second most common (secondary) grades. So in your case you had a G7 (4+3) with tertiary pattern 5. However, in terms of seriousness and risk for recurrence, I have seen studies that estimate the overall score to be roughly equivalent to that of the next higher grade without the tertiary pattern, which in your case would be a G8 (4+4)--you can ask your docs about this.

                The bottom line however, is whether or not further treatment is needed. If it is decided to wait for a future rise in PSA, the tertiary grade can be taken into consideration in deciding at exactly what PSA level you want to initial treatment, i.e., perhaps a little lower than if the tertiary grade were not present.

                Hope that helps,

                Djin
                Last edited by DjinTonic; 08-18-2022, 10:34 AM.
                69 yr at diagnosis, BPH x 20 yr, 9 (!) neg. biopsies, PCA3-
                7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
                6-06-17 Nodule on right + PSA rise on finasteride: 3.6→4.3
                6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
                Nodule neg. for PCa
                Bone scan, CTs, X-rays: neg.
                8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
                SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
                pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma
                5% of prostate (4.5 x 5 x 4 cm, 64 g) involved
                Dry; ED OK with sildenafil
                11-10-17 Decipher score: 0.37, Low Risk:
                5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%                		 9-16-17 (5 wk) PSA <0.1
                (3 m ) 0.010
                (6 m ) 0.009
                (9 m ) 0.007 (nadir)
                (1 yr.) 0.018 (?)
                (13 m) 0.013 (retest)
                (15 m) 0.012
                (18 m) 0.015
                (21 m) 0.015
                (2 yr. ) 0.016
                (28 m) 0.015
                (34 m) <0.014
                (40 m) 0.037 (?)
                (43 m) 0.020
                (46 m) 0.018
                (52 m) 0.023
                (5 yr) 0.038
                (63 m) 0.036
                (66 m) 0.049

                Comment

                • #9
                  7 weeks after surgery my psa is <.03, I'm not sure what kind of equipment the lab uses. It this considered "undetectable" because it does not say that on the results?

                  Comment

                  • #10
                    George,

                    Anytime you see the "<" in front of your PSA score, it means your results were below the detection threshold of the machine and test ordered. So, yes, undetectable.
                    Age Dx: 57
                    PCa History: Father, Grandfathers, Uncles
                    Oct16 Bx: Gleason 4+3 Grade Group 3 w/PNI, LB: 4+3 (60% pattern 4), RA: 3+3, RLM: 3+3, RLA: 3+3
                    Jan17 RALP - Pathology = pT3a; Gleason 4+3; Weight: 42g - Dr. Grant Taylor
                    Jun19 AMS800 installed, Jul19 activated - Dr. David Rapp
                    Sep22 AMS800 failed. Scheduling a replacement if possible.
                    PSA_TESTS: Apr16-5.10, Jul16-4.70, Aug16-5.13, Mar17<0.01, Jul17<0.01, Oct17<0.01, Jan18<0.01, May18<0.01, Nov18<0.01, Jan19<0.01, Jun19<0.02, Nov20<0.10, May21<0.10, Apr22<0.10, Sep22<0.10​

                    Comment

                    • #11
                      That's good news, but there's a saying "hope for the best but prepare for the worst"....

                      While you hopefully would never need it, think about choosing a radiologist and radiation center now, to keep in your back pocket so you can pull the trigger quickly if needed
                      BD: 1959 PSA 4.9 11/2012 (no symptoms)
                      Biopsy 12/2012 Negative
                      PSA 5.9 05/2013 (still no symptoms)
                      Biopsy 6/2013 3+4 (thank goodness for PSA tests)
                      1 core positive (upper left), 1 suspicious (lower left) out of 12
                      DRE: bump right side T1c; PCA-III = 20 (normala)

                      Da Vinci 7/18/2013:
                      Total prostatectomy with seminal vesicles (S13-6085, 1-29, 7/18/13, 29 H&E and 1 paraffin block)
                      Invasive carcinoma involves left lobe of prostate only, extends from left apex to posterior mid region of left lobe Gleason 7/10 (4+3); G4 tumor comprises 75% of invasive carcinoma present
                      Estimated total volume of carcinoma in entire prostate gland: 10%
                      TNM: T2b NX MX (Stage IIA)

                      PSA History:
                      8/13 11/13 2/14 8/14 2/15 8/15 3/16, 8/16, 3/17,9/17,4/18, 9/18 PSA "undetectable" (PSA <.1)

                      March '19 = 0.1
                      April '19 = 0.10 <-- switched to uPSA tests
                      June '19 = 0.10
                      Sept '19 = 0.10
                      Dec '19 = 0.09
                      Jan '20 = 0.13
                      May '20 = 0.2 <- standard test by mistake
                      Jun '20 = 0.11 <- back to uPSA test
                      Aug '20 = 0.16
                      Jan '21 = 0.23
                      Feb '21 =0.20
                      Mar '21 - started ADT/HT, radiation scheduled
                      Jun '21 Eight Weeks Radiation @MSKCC
                      Jul '21 <.05 (T-Level 0)
                      Feb '22 <.05 (T-Level back to normal)
                      Aug '22 <.05 (T-Level still normal)

                      Comment

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