Biopsy Results - PNI for one core

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MoreData
Regular Member


Date Joined Dec 2010
Total Posts : 35
   Posted 1/28/2011 4:47 PM (GMT -6)   
My doc gave me results by phone but I just got a look at the actual report and his summary.

I didn't know I was supposed to be worried about "perineural invasion"! I asked the doc on the phone if there was anything to suggest it had or hadn't spread outside the prostate, and all he said was it was statistically unlikely. Does a 100% core and PNI mean it is likely or has already happened?

Here's my best re-typing of the results. Spell-check is useless, of course.

He says the cancer is "early stage (clinical stage T1c), moderate grade (Gleason score equals 7), adenocarcinoma of the prostate with a PSA of 5.2. Taken together, these are favorable prognostic indicators."

Okay, I like the favorable part.

Here's what came from the cores:
R med apex Vol 5% - G1 3/50 - G2 3/50 - Gleason 6 - no PNI
L lat apex 1/1 Vol 100% - G1 3/80 - G2 4/20 - Gleason 7 - PNI seen (??)
L med apex - Vol 30% - G1 3/80 - G2 4/20 - Gleason 7 - no PNI
L ant - Vol 30% - G1 3/80 - G2 4/20 - Gleason 7 - no PNI
L lat base - Vol 5% - G1 3/50 - G2 3/50 - no PNI

Microscopic Diagnosis:
2, 7-9, 11. Prostatic adenocarcinoma, Gleason score 3+4=7. Focal perineural invasion identified.
1 - right lateral apex - Focal high-grade prostatic intraepithelial neoplasia (HGPIN)
3-6, 10, 12 Benign prostatic tissue.

So here's the question I've been asking for the past two months and with every bit of news: Should I be freaked out?

I have a meeting with Dr. Stricker on Monday (Jan 31). I'll be taking these results, of course, along with the actual slides. I can't wait to hear his opinion.
Age 43 at diagnosis (2011-01) with PSA of 5.2
PSAs 2008-03: 2.6, 2008-06: 3.4, 2008-07: 2.5, 2009-11: 2.9, 2010-12: 6.4
Biopsy 2011-01 - Gleason 7 in 5 of 12 cores - Staged T1c so far
Posts telling the story at .
At my age with 4 young kids I am freaked out and in "GET THAT THING OUT NOW!" mode

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 7584
   Posted 1/28/2011 4:52 PM (GMT -6)   
Researchers still don't fully understand the significance of PNI. Some say it is a good reason to remove nerve bundles but there is no corroborating evidence other than professional opinion. I had PNI and did nerve sparing robotic surgery. So far so good...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

NotHard
Veteran Member


Date Joined Mar 2009
Total Posts : 737
   Posted 1/28/2011 8:26 PM (GMT -6)   
MoreData, Dr Philip Sticker was also my surgeon, and I had a similar path report to yours, actually mine looks slightly worse, higher gleason and PNI. I am now 2 years down the track and doing great. I am very pleased I chose Dr Sticker, as he was highly recommended to me at the time. There are several members here on this forum, under Dr Sticker, and I believe all doing well. Just relax and stay positive.....................Cheers Kev.
Age 53yrs [Gold Coast Qld, Australia]
PSA 4 Gleason 7 [3+4=7]
RP 24/12/08 Dr Philip Stricker [Sydney]
Upgrade Gleason Score 7.6 [4+3=7]
Stage 2 Margin status- Focal Involvement
ED- okay with Meds.
PSA at 2 yrs, no change remains 0.03
"Everyday in Every-way I Get Better'

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3129
   Posted 1/28/2011 9:26 PM (GMT -6)   
Scott- Means biopsy was envolved it hitting nerve/blood source for possible travel...however it is not something to generally freakout about, the name alone scares you...but it is common to have patients found with various cores with PNI and does not necessarily correlate to bad news or prognosis.

Dr Strum a reknown expert in PCa, will mention it in kind of similar terms...like Tony said it is not well determined how significant it really is. So, we focus on Gleason scores, volumes, and other factors. Just for the heck of it ask your doc to run you a nomogram on your stats or do one yourself just to see how that stacks up, still it is only a median averages guideline tool.

My Kreskin like guess is he will say you are a good candidate for any surgery and look to set the date. He will say similar stuff on PNI to what has been mentioned. Yes it could be a travel route, doesn't mean it was or did happen...that is the good news for all PCa patients. We have cure or clear patients whom had plenty of PNI cores, so it is not uncommon I went to Henry Ford also but saw Dr. Menon....he denied me surgery(2002 LRRP)...but my stats were that lousy...the prior doc 2 days before at Michigan Urology Group said curative and 1% chance of incontinence. Imagine that scenario? I got 6 more opinions before making my final decision. Now that is educational.
Dx-2002 total urinary blockage, bPsa 46.6 12/12 biopsies all loaded 75-95% vol.; Gleasons scores 7,8,9's (2-sets), gland size 35, ct and bone scans look clear- ADT3 5 months prior to radiations neutron/photon 2-machines, cont'd. ADT3, quit after 2 yrs. switched to DES 1-mg, off 1+ yr., controlled well, resumed, used intermittently, resumed useage

Post Edited (zufus) : 1/28/2011 7:30:25 PM (GMT-7)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 23863
   Posted 1/28/2011 10:29 PM (GMT -6)   
While most surgeon's opinion downplay PNI significence, I talked to 2 medical oncologist and 3 radiation oncologists and all of them shared the same view on PNI, as being potentially dangerous, and it can allow easy escape for cancer cells. As they told me, it can explain men with quick BCR after surgery that seemed to have pretty clean pathology reports. It can explain how micro-metstasis can happen quickly.

David in SC
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 2269
   Posted 1/28/2011 11:28 PM (GMT -6)   
I would be a little worried about a core that was 100% involved. To my amateur eye, that means there is no "margin"....(of healthy tissue)

On the bright side, your surgeon, knowing this and the location, can carve as big a margin as possible and probably keep it contained...
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT NOW

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 941
   Posted 1/29/2011 4:54 AM (GMT -6)   
Nothard,

Moredata is from Michigan not from Australia so he must be referring to a different Dr Stricker to the one we went to.

Moredata,
 
The news is mostly good in this report, I think. 

There are two areas of concern for me in this report. One is that one core has 100% of cancer potentially indicating involvement of margins (as Fairwind says above) or at least a concentration of cancer in that area. The other aspect is that a lot of the cancer is in the Apex - this is an area that frequently has positive margins as surgeons restore the urethra after removing the prostate. If your cancer was mostly in the transitional zone, surgery would have been a great option as the cancer would be away from the margins. In the case ofthe cancer being concentrated at the apex - an area prone to positive margins anyway I think looking at Brachytherepy would be a good idea.

An
Husband's age: 52. Sydney Australia.
Family history: Mat. grandfather died of PC at 72. Mat. uncle died of PC at 60. He has hereditary PC.
PSA: Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA 27%)|Feb10 - 4.03 (free PSA 31%) |Jun10 - 2.69. DRE normal.
Biopsy 28Apr10: negative for a diagnosis of PC however 3 focal ASAPs “atypical, suspicious but not diagnostic” for PC. Review of biopsy by experienced pathologist, 1/12 core: 10% 3+3 (left transitional), 1/12 core: ASAP (left apex)
Nerve sparing RP, 20Aug10 with Dr Stricker. Post-op path: 3+4 (ISUP 2005). Neg (margins, seminal vesicles, extraprostatic extension). Multifocal, with main involvement in the fibro-muscular zone. T2C.
Post RP PSA,
Lab 1: Sep10 – 0.02|Nov10 – 0.03|Dec10 – 0.03
Lab 2: Nov 10 - 0.01|Dec10 – 0.01

Post Edited (An38) : 1/29/2011 4:05:55 AM (GMT-7)


English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2062
   Posted 1/29/2011 5:10 AM (GMT -6)   
MoreData,

Something I notice from these full details you have carefully typed out is the nature of your Gleason 7.
If I have read the report correctly then you are a 3+4 whch if you are a 7 is better than a 4+3, especially as it says that the highest level of 4 in any of the sample is 20%.

Also of the 12 cores 6 had no cancer in them.

So as a non-expert I sort of agree with the assessment that you have good prognosis.

Alf

Mackattack
Regular Member


Date Joined Jan 2011
Total Posts : 78
   Posted 1/29/2011 6:53 AM (GMT -6)   
An38 and Fairwind bring up a question for me.  When a core is taken, does the sample start at the surface of the prostate, meaning that a 100% core is essentially at the surface?  I had a 90% core which I obviously knew represented a larger tumor than a 50% core, but I didn't think this related to closeness to the surface.
PSA 3.9 - October 2010 at annual physical
PSA 4.1 - November 2010 after a month of antibiotic, DRE Normal
Age 41 in December 2010 at Dx of 6 of 12 cores positive T1C and Gleason 3 + 3

Scheduled for open RP on 2/14/11 at Mass General

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 1611
   Posted 1/29/2011 7:11 AM (GMT -6)   
MoreData,

Welcome to the Forum. My numbers looked a bit worse than yours as I had more cores positive. I was directed to High Dose radiation brachytherapy instead of surgery as the nomograms and Partin tables indicated a significant probability of positive margins with surgery.

You look like you may be a candidate for either surgery or radiation, In the Detroit area you have a well known radiology oncologist, Dr. Martinez. He is a specialist in HDR and I would strongly recommend that you include him in your consultations before making a decision. You can include the website www.cetmc.com in your research. It is very informative.

Please Let me know if you want more details of my experience with HDR and the method I used to reach my decision.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3620
   Posted 1/29/2011 4:25 PM (GMT -6)   
An and Fairwind bring up good points on the 100% core. There have been a few studies on PNI and all have shown no statistical difference in reoccurrances on having PNI on either a biopsy or on final pathology.
The key to a successful surgery is knowing before you go in the precise location of the tumor as this is the largest reason for positive margins.
51% of all positive margins occur in the APEX.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3620
   Posted 1/29/2011 6:33 PM (GMT -6)   
Posted on the New Prostate Cancer Infolink;
 
Lee et all:
 
The authors conclude that the presence of PNI in the prostatectomy specimen was significantly related to biologically aggressive tumor patterns but was not a prognostic factor for biochemical recurrence or cancer-specific survival in patients with prostate cancer.

MoreData
Regular Member


Date Joined Dec 2010
Total Posts : 35
   Posted 1/29/2011 8:30 PM (GMT -6)   
So the call on the PNI appears to range from neutral to moderately negative. I don't completely understand how PNI can be related to aggressive tumors but not to prognosis, but that does appear to be the consensus. I like that consensus. There is still so much I don't know about PC.

That 100% core has me spooked. I wish I understood better how the cores are taken. My initial reaction was it meant the tumor went all the way to the surface but Mackattack may have a point that it's not that simple. I hope he's right.

If the tumor is outside the prostate I hope it's the less agressive 3 cells rather than the 4 cells. With 80% of the cores at 3, statistically it sounds good, but I know the 4s are the ones most likely to venture out.

Part of my problem is I got my bad news in a phone call from the doc who did the biopsy (which was good -- less than a week later) but he just told me it was cancer, G7, contained, and my prognosis was good, good luck with the next set of docs. I'm supposed to get the written report by mail. I picked it up Friday afternoon and am now left the weekend (at least) to figure out what it means. I wish I could have had a chance to ask the doc these questions.

I'll ask the two surgeons I'm meeting with this week (first is Monday the 31st) and the radiation oncologist I'm scheduled with the week following. I suppose their answers will be more important anyway.

In general, I'm exhausted from living in fear for the past two months and in terror for the last five days. I'm eager to get past whatever treatment I choose so I can go back to less-immediate fear over post-treatment PSAs. I'm supposed to be a pillar of strength and courage for my immediate and extended families but not doing so well. I'm so afraid of leaving my wife, missing the rest of my time with the kids, and the twins not even remembering me. As I keep telling people, it's not so much the odds as the stakes that have me scared.

Thanks everyone for the information.
Age 43 at diagnosis (2011-01) with PSA of 5.2
PSAs 2008-03: 2.6, 2008-06: 3.4, 2008-07: 2.5, 2009-11: 2.9, 2010-12: 6.4
Biopsy 2011-01 - Gleason 7 (3+4) 5 of 12 cores - most 5-30% - L lat apex 100% with PNI
Staged T1c so far
A little more of the story at my blog: www.scottontheorwigs.blogspot.com/
Four young kids (10+6+2+2) and a very supportive wife

MoreData
Regular Member


Date Joined Dec 2010
Total Posts : 35
   Posted 1/29/2011 8:37 PM (GMT -6)   
Oh, and I am in the Ann Arbor, MI area so my Dr. Stricker is Hans Stricker at Henry Ford Hospital in Detroit. He also came highly recommended. He works with and learned directly from Dr. Menon. If both Drs. Stricker are equally good, though, I think I'd rather be in Syndney than Detroit at this time of year.
Age 43 at diagnosis (2011-01) with PSA of 5.2
PSAs 2008-03: 2.6, 2008-06: 3.4, 2008-07: 2.5, 2009-11: 2.9, 2010-12: 6.4
Biopsy 2011-01 - Gleason 7 (3+4) 5 of 12 cores - most 5-30% - L lat apex 100% with PNI
Staged T1c so far
A little more of the story at my blog: www.scottontheorwigs.blogspot.com/
Four young kids (10+6+2+2) and a very supportive wife

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 23863
   Posted 1/29/2011 8:58 PM (GMT -6)   
Here's one interesting tidbit on PNI:

http://snr.spl.harvard.edu/publications/item/view/1165
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 23863
   Posted 1/29/2011 8:58 PM (GMT -6)   
Here's an older report, but still has good info in it:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476100/
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 3620
   Posted 1/29/2011 10:09 PM (GMT -6)   
More Data,
The larger the tumor the more chance of it having PNI. It's a simple mathematical relationship based on size of the tumor and size of the gland. The larger tumor will have a greater probability of PNI because nerves run throughout the gland. This does not mean anything else, and the existance of PNI doesn't mean any worse prognosis. A large tumor does directly relate to a worse prognosis.
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2062
   Posted 1/30/2011 4:31 AM (GMT -6)   
If you remove an aggressive tumour early, then it may not matter that it was aggressive if it was still all organ-confined, hence the fact that prognosis can be good.
Alf

zufus
Veteran Member


Date Joined Dec 2008
Total Posts : 3129
   Posted 1/30/2011 5:42 AM (GMT -6)   

(Revised) to reflect more serenity in dealing with it all.

Best to you in whatever your decisions become. It is never an easy road.

 

 

Post Edited (zufus) : 1/30/2011 9:27:03 AM (GMT-7)


MoreData
Regular Member


Date Joined Dec 2010
Total Posts : 35
   Posted 2/20/2011 5:51 PM (GMT -6)   
Belated follow-up with the actual post-op pathology:

The surgeon did multiple frozen sections during surgery of lymph nodes and "tissue" he saw on the urethra. All came back normal.

Contrary to our expectations the Gleason score did not increase on post-op examination. It was still 3+4, and in fact only 5% of the prostate was found to be involved. That biopsy doc must have had very good aim!

Margins, vesicles, and lymph nodes were all negative negative. No extensions.

The last remaining cause for anxiety is the peri-neural invasion, which was seen post-op. Did some of those 4 cells go through the open door to the bloodstream and make a new home? Only the future PSAs will tell . . .
Age 43 at diagnosis (2011-01) with PSA of 5.2
Biopsy 2011-01 - G 3+4=7 in 5 of 12 cores - most 5-30% - L apex 100% w/PNI
Robotic RP 2/9/2011
Pathology - still 3+4, neg everything, only 5% involved
Four young kids and a very supportive wife
No incontinence - ED resolved with Viagra 1 week post-op
More on blog: www.scottontheorwigs.blogspot.com/

clocknut
Veteran Member


Date Joined Sep 2010
Total Posts : 2264
   Posted 2/20/2011 6:41 PM (GMT -6)   
Those sound like nice post-op numbers.  I think you can relax and celebrate President's Day in whatever manner you choose.

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 941
   Posted 2/21/2011 8:41 AM (GMT -6)   
MoreData,

Those are great numbers/words in your post op path report and i imagine you must be very happy that the cancer did not upgrade in gleason score and that the tumour volume was only 5%. congratulations are in order.

Most important thing now is to heal.

All the best,
An
Husband's age: 52. Sydney Australia.
Family history: Mat. grandfather died of PC at 72. Mat. uncle died of PC at 60. He has hereditary PC.
PSA: Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA 27%)|Feb10 - 4.03 (free PSA 31%) |Jun10 - 2.69. DRE normal.
Biopsy 28Apr10: negative for a diagnosis of PC however 3 focal ASAPs “atypical, suspicious but not diagnostic” for PC. Review of biopsy by experienced pathologist, 1/12 core: 10% 3+3 (left transitional), 1/12 core: ASAP (left apex)
Nerve sparing RP, 20Aug10 with Dr Stricker. Post-op path: 3+4 (ISUP 2005). Neg (margins, seminal vesicles, extraprostatic extension). Multifocal, with main involvement in the fibro-muscular zone. T2C.
Post RP PSA,
Lab 1: Sep10 – 0.02|Nov10 – 0.03|Dec10 – 0.03
Lab 2: Nov 10 - 0.01|Dec10 – 0.01
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