Perineural invasion?

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StrictlyInc
Regular Member


Date Joined Dec 2006
Total Posts : 331
   Posted 3/21/2007 2:52 PM (GMT -6)   
My pathology report showed that, while my tumor was confined within the capsule, that I had perineural invasion (focally present).  So I understand this means cancer was found in the nerve sheath surrounding the nerves leading to the prostate. 
 
Questions:
 
- Is this nerve sheath inside or outside the capsule?
 
- I'm guessing this impacts the recovery of the nerves after prostatectomy?
 
I guess I focused so much on the part of the report saying "no capusular involvement" and "negative margins" that I didn't really get into the perineural invasion aspect, but now I'm wondering.
 
confused  
____________________
 
Prostate cancer diagnosed:  May 15, 2006 (age 40)
Gleason score:  3+3=6
daVinci radical prostatectomy:  July 25, 2006
size of tumor:  approx 1.1 inches
post-surgery Gleason score:  3+4=7; negative margins from surgery
number of pads/day at 3 months after surgery:  3 to 5
number of pads/day at 4 months after surgery:  1 to 2
number of pads/day at 6 months after surgery:  0 to 1
1st post-surgery PSA:  0 (Nov 2006)
2nd post-surgery PSA:  0 (Feb 2007)
ongoing post-surgery treatment:  Cialis every other day, Viagra "on-demand", ErecAid pump daily Cialis every other day, ErecAid pump twice daily (when I can manage it)
 


PianoMan
Regular Member


Date Joined Feb 2007
Total Posts : 365
   Posted 3/21/2007 3:59 PM (GMT -6)   
Raheeb: Check with your doctor. I had also had some PNI, but it was within the capsule. There are nerves inside and outside the capsule. Sounds like your sitautaion is the same. I did a little Internet research and found that recent studies show PNI inside the gland has no significnt impact on long-term prognosis. That's the good news.

54 years old

PSA = First ever was 9.8 in late Oct. ‘06, two weeks later, 10.1

DRE: Negative

Biopsy results 11/22/06 (6 out of 8 cores positive), both lobes, Gleason 3+3 = 6

Da Vinci Robotic RP surgery, City of Hope, Jan 12, 2007

Post surgery pathology – Organ confined, Gleason still 6, margins clear.

First post-surgery PSA -- Undetectable, 2/20/07


Swimom
Veteran Member


Date Joined Apr 2006
Total Posts : 1727
   Posted 3/21/2007 3:59 PM (GMT -6)   
Raheeb,

The jury is still out on how significant perineural invasion is to recurring PCa. Some say it's indicative of positive margines if it's found on biopsy. Others say it has zip meaning while others yest suggest perineural invasion has a higher recurrence rate. Since yours was only focally positive on final pathology and your PSA's are responding beautifully, I personally believe this will prove to be of little problem for you. Single focal positives are often just that.... and nothing more comes of them. Check Entrez Pubmed ...go to the urology section and look up prostate cancer to get to their many thousands of abstracts. Urology Times is also a good source for info. Keeping you in my thoughts.....

Be well, Swim

djhouston
Regular Member


Date Joined Jan 2007
Total Posts : 68
   Posted 3/21/2007 6:01 PM (GMT -6)   
Hi All,
That was comforting information to know.

My biopsy said, "T1c, no perineural invasion." My post-op path report said, "T2c, contained in gland - negative margins; definite perineural invasion." I thought, how can this be, because I thought the nerves ran along the outside of the gland, i.e. the possibilty of "nerve sparing" surgery (teasing away the nerves from the gland). So, what is it, capsule-contained or perineural invasion?

Thanks for the info.

dj
dj's stats:
PSA (10/04): 2.9; PSA (2/06):4.4, on Androgel (serum T about 450) at age 56; negative DRE, no symptoms.
PSA (5/06):5.7 with a free PSA% of 8, OFF Androgel (serum T 163). 
Biopsy (5/06): 4/12 samples positive; postitive samples only on right side; max Gleason 4+3=7 (in 2 of the 4 -from area nearest bladder. One was 40% of sample, the others less than a mm. thick.
DaVinci robotic-assisted laparoscopic radical prostatectomy + bladder lift + Right nerve plastic surgery (8/23/06).
Catheter out 4 weeks postop, due to internal pinhole leak at bladder-urethra junction.
Pads-Not needed after about 2 weeks post-cath, but gotta go a lot more often.
Final pathology report:T2c-both sides,but in capsule; neg. margins, neg. lymph nodes, neg. seminal vesicles; final max Gleason still 4+3=7.
1st Follow-up PSA (11/7/06): <0.008 !!!; serum T: 195 - still OFF Androgel (at present). Low T may delay return of erectile function (in presence of one damaged nerve).
2nd Follow-up PSA (3/19/07): <0.003 !!!; serum T: pending.
 


bluebird
Veteran Member


Date Joined May 2006
Total Posts : 2542
   Posted 3/21/2007 7:42 PM (GMT -6)   

Let me know if this helps…. And if not I’ll be happy to delete this post….

 

**Excerpts taken from “Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer”

by: Patrick C. Walsh, M.D. (Professor of Urology, The Johns Hopkins Medical Institutions)

     and Janet Farrar Worthington.   Copyright 2001

 

 

Page 145

**What about Perineural Invasion?

As cancers grow, they compress normal tissue, looking for “elbow room”—spaces with less resistance, where they can spread.  Nerves are usually surrounded by some empty space; for cancer, this is the real estate equivalent of a nice suburban lot with a big backyard—plenty of elbow room.  Thus, it’s not uncommon to find prostate cancer in the spaces around the nerves; this is called ‘perineural invasion.”  Because the nerves are most common close to the surface of the prostate, the findings of perineural invasion on a biopsy suggests that the cancer is close to the edge of the prostate, and may well have penetrated the capsule.  However—this is important to keep in mind—cancer that has penetrated the capsule can still be cured.  Which makes this a paradoxical finding—because, although men with perineural invasion are more likely to have capsular penetration than men without it, perineural invasion has no long-term impact on whether or not a man can be cured.  For this reason, some noted pathologists have suggested that it should not even be commented on when found in a biopsy, because it’s not worth worrying about.

 

~     ~     ~     ~     ~

 

 

Page 289-290

**Excerpts taken from “Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer”

by: Patrick C. Walsh, M.D. (Professor of Urology, The Johns Hopkins Medical Institutions)

     and Janet Farrar Worthington.   Copyright 2001

 

Cancer Control after Radical Prostatectomy

 

There is no better way to cure cancer that is confined to the prostate than total surgical removal.  This is the “gold standard” of treatment, what all other forms of treatment attempt to accomplish.  Thus, it’s important that you understand the results of radical Prostatectomy—just what it can and cannot do—and the fine points in interpreting these results, before you can make an informed evaluation of other treatment approaches.

 

Start with the facts:  The first indisputable fact here is that for any form of treatment to cure prostate cancer, it must be curable in the first place. Is your disease curable?  We can learn almost everything we nee to know about where you stand before surgery from the Partin Tables—the next best thing to a crystal ball—using your clinical stage, PSA, and Gleason score.  After surgery, other information fine-tunes this picture.  The pathologist can determine the facts of your cancer—the Gleason score of the entire prostate, for example (as opposed to the educated guess made by examining just a few cores of tissue).  From the pathologist, we can learn whether the cancer was organ-confined, whether there was capsular penetration with negative surgical margins (also called “specimen-confined” disease), whether the margins were positive, and whether the seminal vesicles or lymph nodes were involved.  All of these factors have a profound impact on the success of treatment.

 

What are surgical margins, anyway?  This is a confusing point for many men.  When the prostate is removed, it should be covered by several layers of tissue.  It may help to think of the cancerous prostate as a gift box (although it’s not much of a present), and the tissue surrounding it as wrapping paper.  After radical prostatectomy, your prostate goes to the pathologist, who immediately coats the outside of the entire specimen—the wrapping paper—with India ink.  The prostate is then put in fixative for twenty-four hours before it is sectioned, stained, and examined under the microscope.  The India ink creates a landmark, so the pathologist can figure out exactly how far the cancer has spread.  It is contained inside the wrapping paper? If the cancer is all contained within the box, we call it organ-confined. Even if cancer penetrates the box (this is capsular penetration), it can still be completely covered with wrapping paper.  We call this specimen-confined.  This is an important concept.  For example, in men with a Gleason score of 6 or below, the long-term outcome is just as good in men with cancer that’s confined inside the prostate (inside the box) as it is in men who have capsular penetration, but negative surgical margins.  If the cancer has penetrated the box and the wrapping paper as well, this is called a positive surgical margin.  The pathologist can see cancer cells at the edge of the India ink, and this suggests that there may be cancer beyond the outermost edge where the surgeon removed the prostate.

 

When surgical margins are positive, or too close to call:

In an ideal world, the pathologist would immediately send a triumphant report to the surgeon:  “I’ve looked at the prostate tissue you removed from Mr. Jones, and all the edges are clear.  Congratulations! You’ve removed all the caner!”

 

Fortunately, it often happens that way.  At Johns Hopkins, fewer than 10 percent of the patients are found to have cancer at the margins—the edges of the removed tumor.  Sometimes, however, the pathologist’s report is more ambiguous.  The report states that the margins are “close,” meaning that cancer is just a hairbreadth away from the edge of the specimen.

 

Expert pathologist Jonathan Epstein, of Johns Hopkins, has good news about these margins:

Close margins are almost always negative.  Epstein recently finished a study of men whose tumors were particularly close—less than two tenths of a millimeter—from the surgical margin.  Even though there wasn’t a comfortable cushion of tissue between the tumor and the edge of the prostate, “those patients do just as well as if there’s more separation between the tumor and the margin.”

 

Even if the surgical margins are positive, this does not necessarily mean that cancer is left behind.  How can this be? “There are several different explanations why, when the margins are positive, the tumor may still be cured,” says Epstein.  “One is that literally, you cut across the last few tumor cells”—that what appears to be remaining cancer is actually a cross section of the perimeter of the tumor. “And even thought it looks like it’s a positive margin, there’s really no cancer left in the patient.”

 

Another explanation is that the act of surgery itself finishes the job, killing any remaining cells.  No cut or injury to tissue happens in a vacuum: the area around the cut is affected, too.  (Think of lightning striking a tree; the tree dies, but so does a ring of grass around it.)  “When the surgeon cuts across tissue, the blood supply is cut off, there’s dead tissue, and that can kill off the last few tumor cells that might have been left behind,” Epstein says.

 

There’s also the potential, “and this probably accounts for a lot of cases,” that it’s an “artifact”—basically, a false positive margin.  Sometimes, “since there’s so little tissue next to the prostate, when the surgeon tries to dissect it from the body, and hands it to the nurse, and then the nurse hands it to the pathologist, everyone’s touching the gland.  If you’re talking about two tenths of a millimeter of tissue, that tissue can be disrupted very easily.  It can appear that the tumor is at the margin—but in fact, there was some additional tissue there that just got disrupted during all the handling.”  In other words, a few good “buffer” cells got rubbed off.

 

And then there’s the sticky cell phenomenon.  When cancer reaches beyond the prostate to invade nearby tissue, it produces a dense scar tissue that acts like super-glue.  As a surgeon removes the prostate, this think scar tissue sticks to the surrounding caner cells—picking them up like a lint brush.  So in some cases, although the pathologist may see cancer cells at the margin—and make a judgment of “positive surgical margins”—there are no cancer cells left inside the patient.  The sticky scar tissue took them all away.

 

Epstein recently studied such instances, where the surgeon removed the prostate, looked at it, suspected that some cancer cells were present, went back and cut out more of the surrounding tissue.  “So in pathology, we got two separate specimens,” says Epstein.  “One was the prostate, one was this extra tissue, the neurovascular bundle that the surgeon was thinking of leaving in the patient, but decided to remove.”  Even when there appeared to be a positive surgical margin at the edge of the prostate, in 40% of these patients, there turned out to be no cancer left behind in that adjacent tissue.

 

“So when pathologist call a positive margin, or for that matter, a close margin, it doesn’t necessarily mean that these patients need some other form of therapy, like radiation—and also that they need not necessarily be tremendously worried.”

 

 

**Excerpts taken from “Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer”

by: Patrick C. Walsh, M.D. (Professor of Urology, The Johns Hopkins Medical Institutions) 

     and Janet Farrar Worthington.   Copyright 2001

 


mama bluebird - Lee & Buddy… from North Carolina

Link to our personal journey…>>>     Our Journey ~ Sharing is Caring 

April 3, 2006  53 on surgery day

RRP / Radical Retropubic Prostatectomy with "wide excision"

PSA 4.6   Gleason  3+3=6    T2a   Confined to Prostate

2nd PSA 02-06-2007 Less than 0.1 Non-Detectable :)

Post Edited (bluebird) : 4/2/2007 8:21:58 PM (GMT-6)


StrictlyInc
Regular Member


Date Joined Dec 2006
Total Posts : 331
   Posted 3/26/2007 2:52 AM (GMT -6)   
Bluebird, thanks for your post, it was quite helpful. Still awaiting more explanation from my surgeon.
____________________
 
Prostate cancer diagnosed:  May 15, 2006 (age 40)
Gleason score:  3+3=6
daVinci radical prostatectomy:  July 25, 2006
size of tumor:  approx 1.1 inches
post-surgery Gleason score:  3+4=7; negative margins from surgery
number of pads/day at 3 months after surgery:  3 to 5
number of pads/day at 4 months after surgery:  1 to 2
number of pads/day at 6 months after surgery:  0 to 1
1st post-surgery PSA:  0 (Nov 2006)
2nd post-surgery PSA:  0 (Feb 2007)
ongoing post-surgery treatment:  Cialis every other day, Viagra "on-demand", ErecAid pump daily Cialis every other day, ErecAid pump twice daily (when I can manage it)
 


StrictlyInc
Regular Member


Date Joined Dec 2006
Total Posts : 331
   Posted 3/30/2007 7:51 PM (GMT -6)   
Well, I spoke to my surgeon. He said that perineural invasion is referring to cancer being detected in the sheath that surrounds nerves leading to the prostate, but not the nerves that control erections (a distinction I wasn't sure about before). He said he feels the research is mixed as to whether this is a sign of greater chance of recurrence. He also said that he thinks chance of recurrence is quite low in my case, and that return of erection function he expects to happen, just a matter of time.

Tick, tick, tick...
____________________
 
Prostate cancer diagnosed:  May 15, 2006 (age 40)
Gleason score:  3+3=6
daVinci radical prostatectomy:  July 25, 2006
size of tumor:  approx 1.1 inches
post-surgery Gleason score:  3+4=7; negative margins from surgery
number of pads/day at 3 months after surgery:  3 to 5
number of pads/day at 4 months after surgery:  1 to 2
number of pads/day at 6 months after surgery:  0 to 1
1st post-surgery PSA:  0 (Nov 2006)
2nd post-surgery PSA:  0 (Feb 2007)
ongoing post-surgery treatment:  Cialis every other day, Viagra "on-demand", ErecAid pump daily Cialis every other day, ErecAid pump twice daily (when I can manage it)
 


balford
New Member


Date Joined Nov 2009
Total Posts : 1
   Posted 11/3/2009 1:00 PM (GMT -6)   
New to this forum...love it!!!!

Just had da Vinci and am healing nicely.

The pathology report after the surgery was a bit troubling until I read Bluebird's post where he referred to excerpts taken from “Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer”

But if anyone can shed any light on the positive results PLEASE let me know:

My pathology report showed the following: (With the troubling parts bolded)
Gleason Score: 6+3+3
Extent of Invasion:
Extracapsular extension: POSITIVE, ANTERIOR
Seminal Vesicle Invasion: Negative
Margins:
Apical: Negative
Peripheral: Negative
Bladder Neck: FOCALLY POSITIVE
Venous Invasion: Negative
Perineural Invasion: POSITIVE
Pathologic Stage: pT3a, pNx, pMx

Thanks!!!

Old Sailor
Regular Member


Date Joined Aug 2009
Total Posts : 192
   Posted 11/3/2009 3:21 PM (GMT -6)   
I asked my urologist at the Mayo Clinic yesterday about perineural invasion (it was the only negative I had on my path report) and he said it was a "secondary" and not too be concerned.  (don't know what secondary meant) Dr. Catalona (expert on PCa) on his website in the answers and questions link says something like all prostates with cancer show perineural invasion and it doesn't mean anything significant.  Hope this helps, the Old Sailor 

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 24282
   Posted 11/3/2009 3:34 PM (GMT -6)   
I know what the great "Walsh" books says about it, was cited above. My uro/surgeon puts little emphais on it, but interestingly, all 3 radiation oncologists I met with, including the one I ended up with, put a strong emphasis on it, and thought the surgical opinion downplaying it to be wrong. They all felt that the nerves are like giant open sewer pipes for cancer cells to easily escape and cause re-occuracne at some future point. Seems to be the typical PC subject, the answers are all over the place and no one really can draw a conclusion.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out  38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - began IMRT SRT - 39 sess/72 gys cath #8 33 days, 11/2- SP Cath #9 in place


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2621
   Posted 11/3/2009 5:57 PM (GMT -6)   
I guess the proof is in the pudding. Seems like the nomogram builders who have thousands of cases to consider should be able to factor it in .

Interestingly enough , Sloan Kettering doesn't even ask about it.

Seems as tho the researchers either haven't considered it, or it is statistically unimportant.

If we are keeping score, my surgeon at Cleveland Clinic says it is insignificant.
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.  Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)

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