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brainsurgeon
Regular Member


Date Joined Jul 2009
Total Posts : 137
   Posted 2/7/2010 3:03 AM (GMT -6)   
I think that reports need to be addressed, both biopsy and surgical pathology reports. As a medical student, I was fortunate to spend a 3 month lay-out quarter working in a hospital pathology department. Since it was in the nation's largest privately owned hospital with about 1200 beds, we had plenty to do back in the 60s. I was also lucky to work with four very nice pathologists who were interested in teaching. Other than a dozen autopsies (also very instructive), I spent all my days cutting surgicals. For whatever reason, surgical pathology was not stressed in our general pathology courses, so my mind was a fertile field to plow.

Each day, I was given specimens removed at surgery to describe grossly into a dictaphone, cut sections (I was taught where to cut on a given specimen), and then read with a double microscope the microscopic slides from those that I had cut two days before. The pathologist was on the other side of the double scope to teach me. It was one of the most rewarding periods in my medical education. With this lengthy preamble, I will now try to get to the point.

We saw a lot of prostate specimens, both whole and chips from trans-urethral resections (TUR). I would guess maybe 20-30 specimens per week. Most of these specimens were sent to us because men had prostatism (BPH) and not cancer. In those days, there was no PSA test, and a man with PC usually came to surgery because of a nodule on DRE. The TURs were the majority unless a man with a so-called "median bar" required open prostatectomy, which was treated with complete removal rather than a TUR.

When examined microscopically, often the chips or the sections of the whole prostate would reveal malignant cell structures. These were usually considered as incidental findings and reported to the surgeon. CT scans were unknown, bone scans were so primitive as to be nearly worthless, and the urologist had to watch for new evidence of recurrence. If bone metastasis showed up on x-rays, then an orchiectomy (testicle removal) was done. Biopsies may have been done back then, but I recall seeing none.

OK. Now to the REAL point of this message, When a pathologist looks at sections of prostate tissue with cancer evident, there is not a little sign there down in the tissue that says "Gleason 4+3, 4+4, or some such". This determination is an ESTIMATE, not an absolute, and it is based on cell appearance. Give the same slides to another pathologist and, you may get a different grading, up or down. The same goes with estimates of per cent of the prostate involved. Of course this is a good reason for multiple readings of slides. I suppose one could send slides to a hundred pathologists, and then take the majority opinion as gospel, but that is ridiculous. In our department, it was standard procedure for more than one doc to look at anything questionable. Disputes were judged by the head man. Gleason was yet to set out his system, so the grades were I-IV, with IV being what is now a Gleason 10.

If you are disturbed by your Gleason score or other micro findings remember the doc is looking at a tiny portion of your prostate on biopsy. In a whole specimen, as a rule, the look is not a lot greater (sometimes our guys would tell us to make more slides of other areas to see further cells). Those scores are not written in stone by any means.
70 years old (1939) USA citizen
Prostatic carcinoma dxed June 2009 by PSA (7.0) and then Bx
PSAs yearly since 2001 ranged 1.52 to 7.0. Doubled from 3.5 to 7.0 in one year.
Neg. CT and Bone Scan
4 of 8 biopsies positive (all right side) Gleason Score 3+4=7
Robotic assisted total prostatectomy and node excision July 2009 in Luzern, Switzerland by Dr. A. Mattei in the Kantonsspital. New Gleason was 4+4=8
pT2c G3 pN0 (0/14)
Catheter out in 5 days (home in 3 days)
No incontinence
Positional neurpraxia in hip and knee resolved 90+% in 5 months.
Potency: beginning tumescence??? at 3 weeks post-op. Still happens at 3 months PO. Nearly usable one month later. At 5 mo. with 100 mg Vitamin V, pretty good. Now beginning 5 mg Cialis daily.
3month PSA less than 0.01
6 month PSA less than 0.01


positional
Regular Member


Date Joined Jan 2010
Total Posts : 25
   Posted 2/7/2010 7:40 AM (GMT -6)   
Hi brainsurgeon,

So, based on your experience, would you suggest to have a second/third opinion on the pathology report?

Mark
Age - 54
Diagnosed - 09/2009
Gleason - 3+3
PSA - 6.7
4 out of 12 cores positive on the left side
MRI shows none on the left side and "cancerous" issues on the right side
RRP on 02/03 with Dr. Lee in Philly
 


brainsurgeon
Regular Member


Date Joined Jul 2009
Total Posts : 137
   Posted 2/7/2010 9:01 AM (GMT -6)   
Why not? Slides are sent in the mails. You don't have to move.
70 years old (1939) USA citizen
Prostatic carcinoma dxed June 2009 by PSA (7.0) and then Bx
PSAs yearly since 2001 ranged 1.52 to 7.0. Doubled from 3.5 to 7.0 in one year.
Neg. CT and Bone Scan
4 of 8 biopsies positive (all right side) Gleason Score 3+4=7
Robotic assisted total prostatectomy and node excision July 2009 in Luzern, Switzerland by Dr. A. Mattei in the Kantonsspital. New Gleason was 4+4=8
pT2c G3 pN0 (0/14)
Catheter out in 5 days (home in 3 days)
No incontinence
Positional neurpraxia in hip and knee resolved 90+% in 5 months.
Potency: beginning tumescence??? at 3 weeks post-op. Still happens at 3 months PO. Nearly usable one month later. At 5 mo. with 100 mg Vitamin V, pretty good. Now beginning 5 mg Cialis daily.
3month PSA less than 0.01
6 month PSA less than 0.01


Herophilus
Veteran Member


Date Joined Sep 2009
Total Posts : 663
   Posted 2/7/2010 9:14 AM (GMT -6)   

My understanding of Gleason is that it is generally accepted that it has about a 90% rate of agreement. That is to say only about 10% of the time would any given number of pathologist report something different looking at the same tissue. So if you got a second opinion and it was the same or without significant difference you should be fairly comfortable with the diagnostic interpretation. Thoughts?

Hero


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4156
   Posted 2/7/2010 10:23 AM (GMT -6)   

The doc makes an excellent point that has been discussed on this forum in the past.  That is that determining G score is art as well as science and that there are a few top dogs with the experience to do it well.  Hence the recommendations given by several of our veteran posters to have slides sent to one of the real experts, e.g. Epstein or Bostwick for a second opinion.

Which raises the question in my mind:  If your uro knows what he/she is doing re PCa, why don't they send the slides to one of the experts to begin with???

Tudpock


Age 62, Gleason 4 +3 = 7, T1C, PSA 4.2, 2 of 16 cores cancerous, 27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 12/09.  6 month PSA 1.4 and now 1 year PSA at 1.0.  My docs are "delighted"!

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 2/7/2010 10:34 AM (GMT -6)   
I have said from the beginning, that the results of a prostate biopsy are at best, an educated and somewhat subjective estimate at best, based on a small sampling of tissue at best.

I would think anything that subejctive to the human eye, trained or otherwise, that they would want each slide to be looked at by at least two different people.

In my case I went into surgery as a 4+3, and according to pathology, 3+4. My post surgery events make it looks strongly that my cancer is acting like a strong 4+3 in its aggressiveness. Perhaps my downgrade in pathology was wrong, and the specimens were misread.

Not sure I will ever know for sure.

Good posting, doctor.
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: 1/10 .12
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 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 2/7/2010 11:44 AM (GMT -6)   
Part of the problem lies in believing that medicine is a science rather that an art

The real issue about a second path reading is "How different would the second reading have to be to cause you to change your mind about your intended course of treatment?"

Suppose that your biopsy shows Gleason 3+4, 50% of 12 cores involved, each core 50% and you are thinking of surgery. How different would a second reading have to be in order to make you think seriously about a different treatment?

Probably the person most likely to change would be one considering AS -- but remember, your program will probably have another biopsy scheduled in about a year.

Finally, remember that your doctor has experience with many path results from the same lab and he gets to see post-surgery results on many of the same patients. Ask for advice based on his experience.
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
9 mo. PSA 0.00 -- 1 light pad/day ED remains


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 2/7/2010 12:18 PM (GMT -6)   
geezer,

you bring up a good point. and if you had the second reading, and let's say it was better or let's say it was much worse, which one would you believe? Now if it came up basically the same, that could be a comfort factor.

But if you thought you were a low grade Gleason 6, and other opinions showed you being a strong Gleason 7, that could radically change one's entire approach to treatment.

Most of us I am certain went with one opinion from one pathology lab, just like I did. I wasn't convinced getting a 2nd opinion on the biopsy work would prove a whole lot with my PSA velocity issues, if anything ,it might have been worse, not better.

Just another area, where the curse of PC makes us decide things that we really aren't qualified to know, and our own doctors won't and can't guarantee a thing either.

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: 1/10 .12
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 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 2/7/2010 12:27 PM (GMT -6)   
I think that Geezer hit it on the head in that most believe that medicine is a science, whereas it is mostly an art. This is true in surgery, radiation, reading scans as well as in pathology.
I think we also fail to note that the Gleason score also depends on where the biopsy needle hits the tumor. In my case the edge of the tumor was a 3+3, futher in was a 3+4, and the center was a 4+3.
Clinical staging is a best an educated guess. The more pieces of information you have and the doctor's skill as a detective will increase the accurracy of the staging, but it is still an educated guess.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT

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