Post Op Pathology Report Questions

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hangin-in
Regular Member


Date Joined Sep 2008
Total Posts : 78
   Posted 9/3/2008 12:57 PM (GMT -6)   

Hi,

I am a 52 yr old that was diagnosed with PC base on a rising PSA from 1.6 to 2.6 within 16 months and a positive biopsy. Gleason was 3+3=6.

I had LRP about two weeks ago and just received the Pathology Report. I am trying to understand it.

 

My biggest concern is what is says under the title Surgical Margin: Tumor present at apical margin. It also states under the title Staging: pT2+ (Confined to the prostate and capsule but extending to margin of resection.)

 

1. Does this mean "positive margin"? Am I right to be concerned that the Dr did not cut it all out? What significance is there, if any, that it is at the apical margin?

2. What does pT2+ mean? I never came across this usually it would be a letter after the T2 as in T2a, T2b, etc. What does the + mean? Closer to T3?

 

I hope I am not asking too many questions, but I am really trying not to panic here.

 

Some other questions that I am wondering about:

1. Gleason score - It confirmed a score of 6 but said Tertiary Gleason grade 4. What does that mean?

 

2. High Grade Prostatic Intraepithelial Neoplasia Identified - My Dr spared the nerves on both sides. Do I have to be concerned that it might have spread to the nerves?

 

I really would appreciate any information on this. This is all new to me and I am trying to find my way. Incidentally I've had full continence thankfully, the day the catheter was taken out but not full erections yet.

 

I have been lurking on this site for a little while and it has helped me immensley. I really appreciate all the information you guys post here.

 

Thanks for all your help and understanding.

LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 9/3/2008 1:26 PM (GMT -6)   
Hangin-in...first of all Welcome to the club even though I know you didn't want to join. I can answer just a couple of your questions.

1. Gleason score - It confirmed a score of 6 but said Tertiary Gleason grade 4. What does that mean?
This would mean that you have a 3 +3 + 4 in that you had some very minor grade 4 cells that were found. You still have a Gleason Sum of 6 however it would actually be somewhere between a 6 & 7 as there is no such think as a 6 1/2 score.

2. High Grade Prostatic Intraepithelial Neoplasia Identified - My Dr spared the nerves on both sides. Do I have to be concerned that it might have spread to the nerves?
High Grade PIN is normally found and is thought to be precursers to PCa, but not necessarily. It would be more like to a benign type of tumor and not cancer. No worry based on this for spreading to the nerve bundles.

Unfortunately I have no idea what a pT2+ is. When do you have your follow-up scheduled with your surgeon. I am sure he can explain what that means. It does sound like to me that it was difficult to determine if the PCa had or had not gone past the capsule because it was so close to the edge of the margins. But I could be completely wrong on that assesment.
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal-Gland 38 cc
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral (Perineural Invasion present at base)
Gleason (3+3) 6  Stage T1C
Robotic Surgery scheduled Sept 18, 2008


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/3/2008 1:37 PM (GMT -6)   
This is not a standard pathology report, but it sounds like it may be stage II. I am guessing that pT2+ means they could see the tumor all the way to the capsule wall but not beyond it. Your Gleason is mostly grade three disease, but some grade four was detected but in small amount. HGPIN is present in almost all pathologies and it is unclear if this is useful information. Some institutions have stopped listing it in their pathology reports. Stay positive in the attitude and hopeful on that first PSA.

Peace,

Tony


Age 46 (44 when Dx)
Pre-op PSA was 19.8
Surgery on Feb 16, 2007 @ The City of Hope
Post-Op Pathology: Gleason 4+3=7, positive margins, Stage pT3b (Stage III)
HT began in May, '07 with Lupron and Casodex 50mg
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 9 '08): <0.1
I will continue HT until May '09. 
Years in Remission (3/23/07): 1
Visit my Journey at:
And at:
 
STAY POSITIVE!
 
 

Post Edited (TC-LasVegas) : 9/3/2008 12:43:07 PM (GMT-6)


hangin-in
Regular Member


Date Joined Sep 2008
Total Posts : 78
   Posted 9/4/2008 11:34 AM (GMT -6)   

Thanks so much for your responses. My next appt with the Dr is at 6 weeks post op. I will try to get more information then.

Do you know if there is any significance that the positive margin was at the apical margin? My Dr mentioned in passing that there is often errors when the positive margin is apical. Did you ever hear of that?

Also, if there was a positive margin I wonder if there is something to do to now prevent a recurrence. Do I just wait to see if my PSA is 0 at 6 weeks and thereafter? Or is there something that I can do now? I hate to have a missed opportunity. I am new to this and trying to find out as much as I can.

Thanks again for all your help!

Hangin


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 9/4/2008 12:35 PM (GMT -6)   
If there is a for sure positive margin, you will likely be pointed to the radiation oncologists office! Since you would know then that residual disease was on the other side of the knife then I would recommend it as well.

Tony
Age 46 (44 when Dx)
Pre-op PSA was 19.8
Surgery on Feb 16, 2007 @ The City of Hope
Post-Op Pathology: Gleason 4+3=7, positive margins, Stage pT3b (Stage III)
HT began in May, '07 with Lupron and Casodex 50mg
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 9 '08): <0.1
I will continue HT until May '09. 
Years in Remission (3/23/07): 1
Visit my Journey at:
And at:
 
STAY POSITIVE!
 
 


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 9/4/2008 2:22 PM (GMT -6)   

Doing a little research for you, it seems that you can have a postive margin when the tumor has reached the stain but still not protruding beyond the capsule.  Sounds confusing, but basically if the tumor touches the stain it is to be reported (standard reporting practice) as a positive margin, regardless if it has extended past the capsule or not.  If it does extend past the capsule that is to be reported as well.  The reoccurence (biochemical failure) outcome for apex vs. base positive margins are different, the latter being the poorer.  Which all this means is that you can have a positive margin yet the cancer not extend past the capsule, which sounds like your case.  It will be important to know if this was a single (focal) site or if there were other sites where the tumor had reached the stain.  Your surgeon will give you all the details on your next visit.

 


Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal-Gland 38 cc
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral (Perineural Invasion present at base)
Gleason (3+3) 6  Stage T1C
Robotic Surgery scheduled Sept 18, 2008


Frank1205
Regular Member


Date Joined Feb 2008
Total Posts : 308
   Posted 9/4/2008 3:48 PM (GMT -6)   

Hi Hangin,

Sorry you are here but glad you came. We are very similar in ways. Here is what I can add.  I too have a positive margin at the apex or top of prostate by the urethra.  I did not find any information that lead me to believe that it is worse or just unusual.  My Doc was surprised to find it there for it is usually lower.  Any way here is what I did.  I got real nervous and then I got my six week PSA.  Zeros good.  Next I was to set up to see the Oncologist then to see a Radiation Oncologist.  Oncologist stated to be safe and increase my odds do minimal external beam radiation.  The radiation oncologist stated I could go either way but if it was him he would radiate.  My 3 month PSA was less than zero again.  I finally found out the length of the positive margin. Pathologist stated less than .5mm.  Maybe two cells left behind worse case.

My Urologist/Oncologist who did the surgery stated that he would do active surveilance and if the PSA even blinks then radiate for sure.  He thinks the bad margin may have been from the handling of the gland itself.  Surgeon to nurse and nurse to pathologist etc.  He also stated that the positive margin does not mean that it is for sure on the other side of the knife but at the edge.  They consider my cancer encapsulated. Surgeon stated sometimes left over cells can just die when the prostate is no longer there.

I will have a PSA every three months and pray and live my life as good as I can in between.  Remember nothing is going to be done before 3-4 months if you decide to radiate.  You need time to heal and get stronger.  There is no hurry here so you have plenty of time to ask your Docs a zillion questions like me and do research and do research as so on. 

Its very hard for you now for you are still early in recovery.  Believe me as you get better you will relax and be able to better focus on this.

My email is listed if you want to go direct with me.

All the best,

Frank

 

 


Diagnosed 01-08-08 @ 53 years old 
DRE normal , 2004 Biospy negative - 2008 Biopsy positive (01-08-08)
10 cores, 1 positive and at 1% of that one core
PSA @ surgery 6 
Bone and Ct scans negative
clinicaly Staged at T1C - Gleason 3+3 = 6
Robotic Da Vinci performed March 27th, 2008
University of Chicago,Hospital stay 30 hours - Catheter out in 7 days  normaly expected leakage Erectile function better with Viagra
Post Pathology T2C, Gleason 7, 10 % of both portions of prostate, Seminal vessels clear, fat tissue clear,Tumor on top of prostate. 1 positve margin measureing less than .5 ml at urethra and bladder..
Six week PSA < 0.1 , 4 month PSA <.05 Gen II test.  Urologist recomends to hold off on Radiation and watch PSA closely. Oncologist and Radiation Oncologist seem to lean to doing pre-emptive radiation.Uroligist says 50/50 chance of PSA re-occurence.  
I have decided to hold off and see for 3 months.
Next PSA October...
 
 
 
 


hangin-in
Regular Member


Date Joined Sep 2008
Total Posts : 78
   Posted 9/5/2008 11:45 AM (GMT -6)   
Wow! Good information. You guys are great. I am really glad I found this site.
 
My doctor did say that the tumor did not extend beyond the capsule although there was a positive margin at the apix. So how does he know it didn't extend beyond if he didn't cut it at the end? Sorry, it's still confusing to me.
 
"It will be important to know if this was a single (focal) site or if there were other sites where the tumor had reached the stain.  Your surgeon will give you all the details on your next visit."
I will definitely find that out at my 6 week visit.
 
Frank - We do have similar situations. Can you let me know what made you decide to wait rather than go with the radiation?
 
Hangin
 
 
 
 
 
 

Rising PSA 12/06=1.6 12/07=2.1 5/08=2.6
Biopsy 6/4/08 Positive
Diagnose @ Age 51 Gleason 3+3=6
Bone & Cat Scans Normal
Lapro Surgery 8/18/08 at Memorial Sloan Kettering
Catheter removed 8/26 - reinserted 8/29 - removed 9/2


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 9/5/2008 12:26 PM (GMT -6)   
Frank - just to clarify something...you said the apex is at the top of the prostate near the urethra? Actually unless I misunderstand you...the base is next to the bladder (which to me means top of the prostate) and the apex is at the bottom of the prostate (closest to the penis). Because there is very little tissue between the bladder neck and prostate it is often very difficult to obtain a clear margin if the cancer is located there which is why when you have a positive margin in this location the outcome for reoccurance is greater. Whereas along the apex there is a larger amount of fatty tissue allowing the surgeon easier access to remove all of the tumor located in those areas. Please correct me if I am wrong or misunderstood you.
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal-Gland 38 cc
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral (Perineural Invasion present at base)
Gleason (3+3) 6  Stage T1C
Robotic Surgery scheduled Sept 18, 2008


BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 9/5/2008 7:05 PM (GMT -6)   
Frank,
LV-TX is correct. Prostate terms can be confusing with the 'base' at the top closest to the bladder and the 'apex' at the bottom, closest to the penis. I guess the terms are based on a somewhat upside down triangle shape. This shows the anatomy:
training.seer.cancer.gov/ss_module02_prostate/unit02_sec01_anatomy.html
Bill
1/05 PSA----2.9 3/06-----3.2 3/07-------4.1 5/07------3.9 All negative DREs
Aged 59 when diagnosed
Biopsy 6/07----4 of 10 cores positive for Adenocarcinoma-------bummer!
Core 1 <5%, core 2----50%, core 3----60%, core 4----50%
Biopsy Pathologist's comment:
Gleason 4+3=7 (80% grade 4) Stage T2c
Neither extracapsular nor perineural invasion is identified
CT scan and Bone scan show no evidence of metastases
Da Vinci RP Aug 10th 2007
Post-op pathology:
Positive for perineural invasion and 1 small focal extension
Negative at surgical margins, negative node and negative vesicle involvement
Some 4+4=8 identified ........upgraded to Gleason 8
PSA Oct 07 <0.1 undetectable
PSA Jan 08 <0.1 undetectable
PSA April 08 <0.001 undetectable
PSA August 08 <.001 undetectable


Every time I see an adult on a bicycle I no longer despair for the human race.
H.G.Wells


Frank1205
Regular Member


Date Joined Feb 2008
Total Posts : 308
   Posted 9/8/2008 4:35 PM (GMT -6)   

Uh, idea Er shocked Um smhair

You guys are very right.  Mine was at the apex at the urethra so that makes sense.  Bottom OOps..

Hangin-in,  as far as the waiting goes that was a tough decision and remains a tough decision.  Radiation Oncologist and Oncologist leaned me toward radiation now.  Urologist/Oncologist (my surgeon) believes and is very convinced that he got it all.  I am going to do PSA's every three months and radiate if the PSA shows any sign of rise at all.  I have a 50/50 chance of reoccurance.  I feel like I am in a Clint Eastwood movie,  "Do ya feel lucky punk?".

Take care.

Frank

 

 


Diagnosed 01-08-08 @ 53 years old 
DRE normal , 2004 Biospy negative - 2008 Biopsy positive (01-08-08)
10 cores, 1 positive and at 1% of that one core
PSA @ surgery 6 
Bone and Ct scans negative
clinicaly Staged at T1C - Gleason 3+3 = 6
Robotic Da Vinci performed March 27th, 2008
University of Chicago,Hospital stay 30 hours - Catheter out in 7 days  normaly expected leakage Erectile function better with Viagra
Post Pathology T2C, Gleason 7, 10 % of both portions of prostate, Seminal vessels clear, fat tissue clear,Tumor on top of prostate. 1 positve margin measureing less than .5 ml at urethra and bladder..
Six week PSA < 0.1 , 4 month PSA <.05 Gen II test.  Urologist recomends to hold off on Radiation and watch PSA closely. Oncologist and Radiation Oncologist seem to lean to doing pre-emptive radiation.Uroligist says 50/50 chance of PSA re-occurence.  
I have decided to hold off and see for 3 months.
Next PSA October...
 
 
 
 


hangin-in
Regular Member


Date Joined Sep 2008
Total Posts : 78
   Posted 9/9/2008 11:27 AM (GMT -6)   

Frank,

Thanks for your post. I wish you the best.

I kind'a have mixed feelings right now. I am thankful that I had full continence from the minute the catheter was out and I have no ED problems at 3 weeks post op. ( Although Mr Happy is still sore from the catheter  wink ). But did this come at a high price? confused Is that why I have a positive apical margin?

Who knows... I am really eager for my 6 week PSA test result - due on Oct 2 2008.

Good luck to you.

Hangin


Rising PSA 12/06=1.6 12/07=2.1 5/08=2.6
Biopsy 6/4/08 Positive
Diagnose @ Age 51 Gleason 3+3=6
Bone & Cat Scans Normal
Lapro Surgery 8/18/08 at Memorial Sloan Kettering
Catheter removed 8/26 - reinserted 8/29 - removed 9/2

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