Perineural invasion question

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LuvMyDAD
Regular Member


Date Joined Dec 2009
Total Posts : 315
   Posted 12/16/2009 9:09 PM (GMT -6)   
I have a question for anyone who knows anything about perineural invasion on biopsy..
My dad was found to have perineural invasion on biopsy. His surgery is coming up and I am getting worried about the post-op path report. Has anyone had a perineural invasion on biopsy and turned out to have negative margins?
Any information on this would be greatly appreciated. Thank you.
LuvMyDAD

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 12/16/2009 9:16 PM (GMT -6)   
Many doctors ignore this, saying that most biopsies show it. It really doesn't relate to margins.

Others contend that it is an open highway to the lymph system, and it could be, but if you start reviewing signatures on this site, you will find many with perineural invasion who have had good results.

Some of the margin results are dependent on the surgeon. If he/she can detect where the tumor is, they will take a bigger piece of the adipose tissue in that area. If there is perineural invasion, they will take some or all of the nerve. Other less experienced surgeons just cut the nerves, hence non-nerve sparing surgery.

Goodlife
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 .
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)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injections


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 12/16/2009 10:00 PM (GMT -6)   
Most perineural invasions are microscopic, that is less than 1/10 mm. So I wouldn't get excited until the path report after the surgery
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads
6 mo. PSA 0.00 -- 1 light pad/day


LuvMyDAD
Regular Member


Date Joined Dec 2009
Total Posts : 315
   Posted 12/17/2009 12:32 AM (GMT -6)   
Hi Geezer, sorry I did not quite understand your response.
Microscopic in the sense that I shouldn't be too concerned?
 
Goodlife, I hope you are right. I just read online about it being an escape tunnel and I am getting really anxious.
 
Another question to anyone out there....has anyone been downgraded post-op? Does it happen, or its more likely to be upgraded?

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 12/17/2009 5:53 AM (GMT -6)   
Perineural invasion is very common and isn't necessarily associated with positive surgical margins. Many a post surgery pathology says there is perineural invasion but also says negative surgical margins. It is usually talking about the nerve pathways contained within the prostate gland. All it means is that that particular biopsy sample hit a tumour containing nerve pathway within the gland. Take mine. Negative for perineural invasion at biopsy (obviously the needles missed the nerve pathways) but extensive perineural involvement revealed at post surgery pathology with negative surgical margins. I wouldn't be particularly concerned about it at this stage.
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 (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
PSA August 09 (2 year mark), <0.01
PSA December 09 <0.01

My Journey: www.yananow.net/Mentors/BillM2.htm

Post Edited (BillyMac) : 12/17/2009 4:56:22 AM (GMT-7)


Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 12/17/2009 6:28 AM (GMT -6)   
Luv, don't worry about the PNI ... it's a very common finding on biopsies. I too was concerned since it was noted on John's biopsy path report. His surgical path report confirmed PNI but it didn't seem to have any effect on the surgical margins (which were negative).
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (single small EPE in posterior left). Perineural tumor infiltration present. Apex margin, bladder neck and SV negative. Final Gleason 3+4. PSA: 0.0 til July 2009. August 2009- 0.1, September 0.3, October back to 0.0, December 0.0. Thank you God!


O Buddy Boy
Regular Member


Date Joined Oct 2009
Total Posts : 106
   Posted 12/17/2009 6:42 AM (GMT -6)   
From the charts I've read PNI is not used to predict long-term outcomes. They found it in me and I had negative margins.

I was told nothing to worry about, move along in my life.

OBB
55 yo
Dx:9/29/09
DRE: Susp
PSA: 3.5
Gleason: 3+4/7
6/12 Cores Positive; Sextants were 1%, 3%, 8%, 15%, 12%, 0%
RALP: 10/09/09
PATH:
Margins: Clear
Lymph Nodes: Clear
Seminal Vesicles: Clear
Gleason: No increase from biopsy 3+4/7
Some perineural and capsule invasion.
T2c,NO,MX
Incontinence: Minor. 1 light pad a day. Some days don't need it.
ED: Natural with encouragement. 20mg Cialis and pump just makes things more fun.


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 12/17/2009 8:06 AM (GMT -6)   
PNI is in the nerves inside the prostate and not necessarily related to the nerve bundles around the outside of the prostate. Very common, so common that most labs don't report it anymore on biopsy. Pathology from surgery most likely will show PNI.

The tiny space around the nerves on the inside of the prostate are believed to be a source for a pathway for the cancer to escape. But this thought is still being debated and so far there hasn't been any positive proof that it does.

I had it on my biopsy, and like others said...don't worry about the PNI.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral w/PNI - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month Apr 2009 .06
                   9 month Jul  2009 .08
                 12 month Oct 2009 .09 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/17/2009 9:15 AM (GMT -6)   
I will present the opposite view of PNI from my own case. It showed up in my biopsies (3), and showed up again in my post surgery pathology report. My surgeon said it could mean something later on, but not to worry about it.

In my case, dealing with some steep PSA velocity in the year or two before surgery (Background note)

Within 9 months of surgery, had confirmed reoccurance. Just completed IMRT for salvage. (39 sessions)

I met with 3 different radiation oncologists before choosing the one that I went with. All 3 of them, put a lot of stock in the importance of PNI. They strongly believe that it can be an easy gateway for PC cells to escape. And in cases of high psa velocity they felt it was the likely reason there was such early reoccurance. My very case may be proof of their theory on PNI.

It was part of the formula why I was given so much radiation on the salvage.

Should you worry about that now? No. But keep it in the back of your mind. Shows that a good radiation oncologist and a good surgeon can have two different views about the same thing.

David in SC
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
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA:
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 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 in place


LuvMyDAD
Regular Member


Date Joined Dec 2009
Total Posts : 315
   Posted 12/17/2009 4:04 PM (GMT -6)   
Thanks David for your reply. That is what I keep reading, its a form of escape. Reading stuff online can make someone crazy, the only way I can get some relief is by coming here.
Can I ask you, if you have a psa recurrence after surgery does that mean chances of a cure are gone?
Another question (sorry I ask too many), was everything else in your path negative except for a positive margin?
Thanks,
LuvMyDAD

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/17/2009 4:21 PM (GMT -6)   
First, ask away, from all of of us. There is no such thing as too many questions here, no such thing as a dumb question. I can't take credit for this quote, I picked it up here, but the best way to overcome fear with PC, is with knowledge.

Second, I am not a dr nor have any qualifications, I am answering based on how my team of doctors answered me in my case.

Thirdly, a positive margin does not mean you will have reoccurance, but it can. And we have men without positive margins, that do have reoccurance. That is the annoying thing about PC, it doesn't follow the rules of fairness or consistency.

Fourth, you asked if you have a psa reoccurance after surgery, does that mean chances of cure are gone. No way to know or answer that precisely. The great unknown in that situation is the reoccurance local, i.e. to the prostate bed or general region, or has it metasizied elsewhere in the body, or also, it can be both at the same time.

With our present technology and testing, and please someone step in if I am wrong on this point, there is no accurate fool proof way to know the difference.

With some men, let's say they have surgery, and it fails like mine did, and then they have radiation, and for all reasonable purposes, they are "cured". With other men, even the radiation can fail. If the radiation fails as a salvage, then the PC is said to be no longer curative.

Its not like I am beating around the bush, or other posters here, but PC again, has its own rhyme and reason. If we only knew from the start whether our cancer was indolent (not likely to ever turn agressive in our lifetime), or agressive, and just waiting to get you, we would be so much better off after we get our diagnosis. We have men that have surgeries that are never needed, and men that have surgeries that are destined to fail, and men that have surgeries that work. And not just surgeries, but whatever primary treatment they choose would have the same choices of outcomes.

I am glad your dad has you. Can't remember seeing your name, so not sure if you are a son or daughter, but I am so glad that my adult age children live close to me, and all take an active role in keeping a close eye on the old man. Bless you for that.

David in SC
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
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA:
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 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 in place


LuvMyDAD
Regular Member


Date Joined Dec 2009
Total Posts : 315
   Posted 12/18/2009 10:04 AM (GMT -6)   
Thanks David. I am actually a daughter and to be honest I am scared to death of this thing.
It's so weird, everyone talks about prostate cancer as being the best kind of cancer to get, but it seems like other cancers you can be cured at the 5 year mark but this one can haunt you forever. I guess the prostate is more complicated then other organs.

I keep reading and reading but I guess nothing is going to make a difference at this point until we get the pathology report back. I guess all I can do now at this point is pray.
Thanks again for your help.

LuvMYDAD

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/18/2009 10:50 AM (GMT -6)   
Your dad is lucky to have a caring daughter like you. Even at age 28 and married, my daughter is still a daddy's girl. Yes, wait patiently for that full pathology report and try not to read too much into it. For many men with low grade prostate cancer , the cure rate is still real high. And even for the me with more agressive cancers or advance cases, still lots of avenues of hope.

I think you are doing fine.

David in SC
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
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA:
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 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 in place


Rolerbe
Regular Member


Date Joined Dec 2008
Total Posts : 235
   Posted 12/18/2009 11:04 AM (GMT -6)   
LuvMyDAD said...
It's so weird, everyone talks about prostate cancer as being the best kind of cancer to get ...
 
Yeah, those are the people who have never had to face it directly.  I know.  I was one of them.
 
Had a 31 y.o. friend who came to me one day at work to tell me he had to take a day off to have a skin cancer lesion removed.  Startled me, but I said at least that's one of the ones with a simple treatment, you'll be OK.  He was gone two months later.
 
Still didn't learn my lesson, and thought about Lance Armstrong's testicular cancer "well, that was just a simple treatment for an isolated problem." Then read his first book detailing his trials and tribs with met's to the brain and lungs, etc. and was again shamed by my cavalier, dismissive response.
 
I work in the engineering field where we talk about six-sigma quality -- 99.99966% success.  That's about one error per 1,000.  The medical community will say that PCa has minimal life risks -- only about 1 in 10 over 15 years.  But that's hardly even three sigma.  And we're not talking about parts on an assembly line!
 
'Best' kind of cancer to get is faint praise indeed...

Your dad's chances are very 'good' and I hope for the best possible outcome for you.  But we still have a long way to go in general with cancer treatment.


51 YO
PSA at Dx: 8.2
DaVinci RALP: 10/31/08 -- Great MD in New Haven, CT
Negative margins, no extra-capsular involvement
One nerve spared
PSA at 0 for just over a year now.
 
 

Post Edited (Rolerbe) : 12/18/2009 10:08:00 AM (GMT-7)


Herophilus
Veteran Member


Date Joined Sep 2009
Total Posts : 662
   Posted 12/18/2009 4:51 PM (GMT -6)   

Rolerbe:  So wonderfully stated. Kind of made me teary eyed for I too have made that cavalier statement which begins “well at least its only”…dang I still feel like a fool. We use Lean and Six-sigma in health care all the time; but when you become a member of the “Ca” group in the fraction Ca/P things change….

Hero


Age 51, PSA 08/31/2009= 6.8, DRE Neg.
Biopsy 9/24/09 =10 of 12 positive. Gleason 6. 75% of one core.
da Vinci at Wash U, Barnes on 11/02/09
Pathology Changed Gleason to 4 + 3 = 7. Gleason 7 present in all 4 quadrants
All(4)periprostatic Lymph Nodes Negative, All(10)pelvic Lymph Nodes negative
Seminal Vesicles tumor free. No prostate extension


mvesr
Veteran Member


Date Joined Apr 2007
Total Posts : 823
   Posted 12/18/2009 6:24 PM (GMT -6)   
Hi

I had PNI in my biopsy patjhology report. My first urologist told me it would do no good to have surgery because of PNI the cancer had escaped the prostate. I was not happy with that so I sought a second opinion. After two and a half years I had had less than zero PSA's every time.

Take care

Mika
age at dx 54 now 57
psa at dx 4.3
got the bad news 1/29/07
open surgery Duke Medical Center 5-29-07
never more than 2 pads
ED is getting better
the shots work great, still can't give them to myself
two years of zero's


Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 12/18/2009 6:43 PM (GMT -6)   
Luv, your statement that other cancers can be cured at the 5 year mark but prostate cancer is one that haunts you forever is not completely accurate. Any person who has been treated for cancer - any cancer - can have a recurrence. The recurrence can happen almost immediately after treatment, a year later, 5 years later, or even 15-20 years later. All cancers require diligence for the person's lifetime. I think the difference with prostate cancer is that no chemotherapy has been established to fight the disease from the beginning. We rely on surgery or radiation as the primary first-line treatments, and these are both local treatments rather than systemic like chemotherapy. If there's a recurrence, right now there doesn't appear to be a test that can determine if it's local or systemic. With most other cancers, you can do PET scans to see how far the cancer has progressed and where it has spread. I don't believe that prostate cancer is more difficult to treatment; I think it just plays by different rules than other cancers.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (single small EPE in posterior left). Perineural tumor infiltration present. Apex margin, bladder neck and SV negative. Final Gleason 3+4. PSA: 0.0 til July 2009. August 2009- 0.1, September 0.3, October back to 0.0, December 0.0. Thank you God!


soulmate 101
Regular Member


Date Joined Jan 2010
Total Posts : 57
   Posted 1/22/2010 6:53 PM (GMT -6)   
LuvMyDad, this is an earlier thread, and I know your Dad's pathology report was downgraded after surgery, so that is wonderful. Still the PNI caught my eye here, my husband had PNI noted on his surgical pathology, but had negative surgical margins and no lymph or seminal vesicle involvement.

As others have stated here, I suppose stats and information give us a guideline, and then there is that element of unpredictability that is just part of life. I have a child who was given a 30-45% chance for survival when he received his diagnosis of cancer as a baby, and is alive and thriving disease free more than a decade later. However I think that a cancer diagnosis does change your life forever. Not that it dooms you, but that it can make you more aware.

Having said that , this prostate diagnosis for the love of my life has thrown me a loop for sure.
Life sure can it's way with you.

I also want to comment - one of the hardest things in digesting my husband's diagnosis was very well meaning friends who made comments like, "Oh that's the good kind of cancer to get" or "Well at least it won't impact your life that much, " or "They've come a long way in treatment options." etc. etc. etc.
Unfortunately, one doesn't become "expert" or informed until it happens close to home and then you quickly research all the ways it does impact your life.
I'm so grateful to the "veterans" here. Thank you for sharing your experiences, the good the bad and the ugly. It's very generous.
Husband, age 57, diagnosed in December 09, Gleason 4+3 = 7 stage T2c, laparoscopic nerve sparing Da Vinci robotic radical prostatectomy 1/13/10, clear surgical margins no lymph node or seminal vesicle involvement.
Let the healing begin...

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