Understanding pathology

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Regular Member

Date Joined Dec 2008
Total Posts : 60
   Posted 2/20/2009 11:02 AM (GMT -6)   
I have gathered all of my medical records ref: this journey.  My original biopsy path said G6.  The slides were sent to the doctor at Cleveland Clinic because he wanted his own path report.  They said G7(3+4).  The post surgical path report said G6.  I am happy with the results but I do not understand.  I can understand and increase in the gleason because of interpretation.  I do not understand when the same hospital reads an individual 4 from a biopsy and then after examining it post surgery they read a 3.  If they saw a 4 in the biopsy slides how can it be reduced.
Age at Dx:48, currently 49
PSA May 08 2.96
referred to uro
PSA June 08 3.44
biopsy 7/25/08-29 core samples
path 7/31/08-8 of 29 PCa/10% involved L/R base and mid
high grade PIN in apex/seminal vesicles clear stage GS 3/3=6 pT2a
10/7/08 robotic at Cleveland Clinic-Dr. Kaouk
10/10/08 path GS 3/3=6 pT2c
cancer contained/neg margins
PSA Jan/09 .03

Veteran Member

Date Joined Dec 2008
Total Posts : 3149
   Posted 2/20/2009 12:21 PM (GMT -6)   
Not a surgery guy so cannot answer this as someone else might. Some general observations on PCa concerning pathology in general: it is actually an art and not pure science, different pathologist come up with different opinions many times (PCa is fully of inconsistencies on all matters). Secondly, the sample chosen post surgery is not the same sample seen from biopsies from slides, in case you did not know you can have multiple gleasons within your gland and including PIN or HG PIN (which you have listed in your bio). My 12/12 biopsies showed 3 different Gleasons scores twice over because found about equally on both sides, (2) 7's (3+4) and (2) 8's,(3+5 & 4+4) and (2) 9's (4+5)
rather ominous with 12/12 biop. and everyone 80-95% cancer and psa of 46.6 but still here to talk about it and doing well thus far for 7 yrs. post diagnosis. (current psa is .36-.39 area)

Veteran Member

Date Joined Jul 2008
Total Posts : 966
   Posted 2/20/2009 12:53 PM (GMT -6)   
I may be way out here...but when the pathologist exams the tissue after removal...isn't a bit like slicing a loaf of bread? They can examine what is seen on the surface of the slice, but not in the middle. So in effect the needle biopsy might be picking up just a few grade 4 cells, but on the surface of the samples that the pathologist can examine only shows the grade 3. Maybe a reason for the difference? Geez...it's so confusing.
You are beating back cancer, so hold your head up with dignity
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
August 23 - Bone Scan - Hips, Spine and ribs marked uptake - X-Ray showed clear -Hooray
Sept 9 2nd DRE - questionable - TRUS...shadow in base - Gland now 41 cc
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (4+3) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
4 tumors in prostate - largest being 6 cm 
PSA 5 week Oct 2008 <.05
       3 month Jan 2009 .06

Elite Member

Date Joined Oct 2008
Total Posts : 25382
   Posted 2/20/2009 3:06 PM (GMT -6)   
And despite how much we want to view the pathology as purely scientifice, I have read where there is still a subejctive interpatation to what is being viewed, particually if it is a close call on the sample.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3
3rd Biopsy 9/8 Positive 7 of 7 cores pos, 40-90%, Gleason 7
Open RP surgery 11/14/8, Right nerves saved, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05

Regular Member

Date Joined Apr 2008
Total Posts : 270
   Posted 2/20/2009 3:33 PM (GMT -6)   

I believe the only logical answer is that different people are evaluating.  If it is the same people evaluating then they changed their mind.  It is obviously difficult to rate borderline degrees of cancer cells.  The biopsy is just a snapshot of specific areas, while the pathology is looking at the whole thing.  You are correct in that if there was any 4 rated gleason it should have been a 3x4 on the pathology.  In fact most of the time the pathology, if it is different, is usually worse for that very reason. 

The good news is that your pathology was an improvement, and that is a blessing.

Age 61 (now 62)
Original data - pre-operation
PSA: 5.1
T1C clinical diagnosis, Needle biopsy - 10 cores, Gleason 7 = 3+4 in 1 core (40%), 7 cores Gleason 6 = 3+3 ranging from 5% to 12%
All scans negative
Lupron administered 4/9/2008 for 4 months (with idea I would undergo external beam radiation followed by seed implants - then I changed my mind).
Robotic DiVinci surgery - Dr. Fagin (Austin) May 19th
Post operative - pathology
pT2c NX MX
Gleason 3+4
Margins - negative
Extraprostatic extension - negative
seminal vesicle invasion - uninvolved
1st Post PSA <.04
2nd Post PSA <.01 10/30/2008

Regular Member

Date Joined Jan 2009
Total Posts : 180
   Posted 2/20/2009 4:45 PM (GMT -6)   
Hi Tim,

I have no idea wha the G reference is but it looks like your surgery was successful. Please ask the Dr who gave this classification and tell us what they say. Best wishes.

Diagnosed @ 48yo 04/07
focal, low volume tumor gleason 6
RRP 07/30/07 robotic
Persistance of PSA
IMRT 11/07-01/08
Emerg, cysto obstructed bladder 01/08
Persistance of PSA
08/08 learned Dr. left significant amount of prostate
12/08 PCA3 negative
12/08 saturation biopsy 36 cores 24 having normal prostate tissue
12/08 referred whole to med malprac attorney

Veteran Member

Date Joined Feb 2008
Total Posts : 1858
   Posted 2/20/2009 5:54 PM (GMT -6)   
There was a quote somewhere from a renowned doctor who said "tell me what Gleason you want and I'll tell you which pathologist to check the specimen." I think it is a case of "beauty is in the eye of the beholder" and the what the pathologist believes he sees. Perhaps it was a different pathologist within the group.
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 (disregarded due to lab "misreporting")
PSA August 08 <0.001 undetectable (disregarded due to lab "misreporting")
Post-op pathology rechecked by new lab:
Gleason downgraded to 4+3=7
Focal extension comprised of grade 3 cells
PSA September 08 <0.01 (new lab)
PSA February 09 <0.01

Veteran Member

Date Joined Apr 2006
Total Posts : 1732
   Posted 2/20/2009 6:01 PM (GMT -6)   
Post operative pathology is more accurate because there are larger samples available to work with than those tiny biopsy samples. Most pathologists will go higher, not lower on Gleason scores. Notice there aren't too many low Gleasons being diagnosed these days?


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