Is it weird that my lymph nodes were not examined during prostatectomy?

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Veteran Member

Date Joined Aug 2010
Total Posts : 644
   Posted 8/30/2010 6:11 PM (GMT -6)   
Hi -

I was just looking at the actual pathology report from my robot-assisted prostatectomy 7 months ago, and noticing that it said
"Lymph note status: none present"
"AJCC/UICC stage: pT2cNX"

I assume that means that my lymph nodes weren't examined.

I've reviewed a few journal articles on PubMed and it seems that lymph node dissection is pretty much routine in cases of intermediate and high risk cancer.

It seems that in most research, either PSA>10 OR Gleeson >6 OR DRE+ (clinical T2) makes a cancer "intermediate risk" not a "low risk" cancer. My key stats -- Gleeson 3+4=7, PSA 5.6, clinical T1c -- would seem to put me in the intermediate range (due to the Gleeson 7.) In addition, my PSA shot from 3.6 to 5.6 in 3 months, and I think this would also nudge my cancer to the intermediate range if not higher .

Is it odd that my nodes were not examined?
DX at age 54 12/2009
Initial clinical profile: PSA 5.6, DRE-, high pre-op PSAV. Clinical stage T1c
Biopsy: Gleeson 3+4 with PNI / 6 of 14 cores + / 10% of total length + / worst core 45% +
TX: Robotic assisted RP 2/2010
Pathology: pT2cNx / Gleeson 3+4 / PNI+ / SM- / SV- / EPE- / Tumor vol 7% / prostate vol 40cc
PSA - post-op 0.01

Veteran Member

Date Joined Nov 2009
Total Posts : 7270
   Posted 8/30/2010 6:30 PM (GMT -6)   
Not to hijack your thread, but they did examine 3 lymph nodes for me.
I've been reading that they should take more (although there is more risk of complications).
Perhaps others can weigh in.
PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (PSAf: 24%), PCA3 =75 .
Biopsy 11/30/09. Gleason 4+3. Stage: T1C. Current Age: 64
Surgery: Dr. Menon @Ford Hospital, 1/26/10.
Pathology Report: G 4+3. Nodes: Clear. PNI: yes. SVI: No. EPE: yes. Pos. Margin: Yes-- focal-- 1 spot .5mm. 100% continent by 3/10. ED- in progress. First post-op PSA on 3/10/10-: 0.01. PSA on 6/21/10--0.02. Next PSA late Sept.

Veteran Member

Date Joined Apr 2008
Total Posts : 1132
   Posted 8/30/2010 6:34 PM (GMT -6)   
I would go back and ask the surgeon to explain. I had one tested during my surgery. Like Mel, I've heard you should have more than one tested but never heard of them not testing any.
Age 48 at diagnosis
occupation accountant
PSA increased from 2.6 to 3.5 in one year
biopsy march 2008 - cancer present gleason 7
Robotic Surgery May 9, 2008 - houston, tx
Pathology report -gleason 8, clear margins
22 month  PSA <.04
continent at 10 weeks (no pads!)
ED is still an issue

Veteran Member

Date Joined Jan 2009
Total Posts : 2243
   Posted 8/30/2010 7:28 PM (GMT -6)   
My path report just says not identified, but will go back and read it again.
Dx with PCA 12/08 2 out of 12 cores positive 4.5 psa
59 yo when diagnosed, 61 yo 2010
Robotic surgery 5/09 Atlanta, Ga
Catheter out after 10 days
Gleason upgraded to 3+5, volume less than 10%
2 pads per day, 1 depends but getting better,
 started ED tx 7/17, slow go
Post op dx of neuropathy
T2C left lateral and left posterior margins involved
3 months psa.01, 6 month psa.4, 6 1/2 month psa.5 on 11/28/10
Starting IMRT on 1/18/10, Completed 39 tx at 70 gys on 3/12/10
6 week Post IMRT PSA .44 a drop from .5 but maybe more
Great family and friends

Forum Moderator

Date Joined Jan 2010
Total Posts : 7087
   Posted 8/30/2010 7:59 PM (GMT -6)   
At the top of my report there was an inventory of the samples. You might check that - perhaps there were some, but they did not find anything?

My surgeon told me he would take some, and that there would be a quick path check before deciding to continue. It seems there would be a point at which they say no, it's too far gone, close it up -. They took 12, but then I was clearly high risk. G 4+4 in 9/12 biopsies, 4+5 post surgery.
My IGRT journey -

Tony Crispino
Veteran Member

Date Joined Dec 2006
Total Posts : 8128
   Posted 8/30/2010 8:09 PM (GMT -6)   
Well your results look good so far.

Yes they should have pulled some of the local nodes. But I do know of a couple surgeons that do not do it ever.

Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog :

Regular Member

Date Joined Aug 2010
Total Posts : 245
   Posted 8/30/2010 8:50 PM (GMT -6)   
Husband with stats slightly less threatening than yours had an open manual rad. prostatectomy and had the following removed in addition to the prostate: right 10 pelvic lymph nodes, negative for tumor and left 2 pelvic lymph nodes, negative for tumor post surg. His AJCC classification: pT2c NO

Call the doc and find out. Perhaps (speculating) your "lymph node status: none present" meant there was no cancer present. Hope that was the case, but your take on it sounds more likely...
Husband 60yrs., no symptms: PSA 10/04 2.73, 12/06 3.64, 5/09 3.9, 10/09 4.6, 1/10 5.0w/ free PSA 24
6 core biop 4/1/10 path rept: rt mid: adnocarc. G=3+3, 5% of core; R apx v. susp. minute ca, R base bnign w/ mod. atrophy, L side atrphy only; 2nd opnion JH confrmd
MRI - 15mm nodule
BiLatRP surg 7/6/10, path: T2c, nodes, sem.ves, extra caps. neg., adenoc both sides G=3+3 cntinent, Viagr-8/27 ED

Veteran Member

Date Joined Jan 2010
Total Posts : 1011
   Posted 8/30/2010 9:20 PM (GMT -6)   
I had 9 nodes checked before the prostate was removed. I don't know what the right number is, but I thought it was standard practice. If they find positive nodes they don't operate.
Dx with PC Dec 2008 at 56, PSA 3.4

Biopsy: T1c, Geason 7 (3+4) - 8 cores taken with 4 positive for PCa, 30% of all 4 cores.

Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%
nerves spared, no negitive side effects of surgery

One night in hospital, back to work in 3 weeks

psa Jun 09 <.01
psa Oct 09 <.01
psa Jan 10 .07 re-test one week later .05
psa Mar 10 .28 re-test two weeks later .31
psa May 10 .50

April 10 MRI and Bone Scan show lesion on lower spine, false positive.

Started HT 5/25/10 with 3 month shot of Trelstar. SRT scheduled for late July

psa July 10 <.01 HT at work

Veteran Member

Date Joined Oct 2006
Total Posts : 1211
   Posted 8/30/2010 9:21 PM (GMT -6)   
My surgeon told me that he would remove some lymph nodes first during the open and if found to be +ve he would not continue with the operation. I would find it very strange if no nodes were taken during your operation. But then again.....what do I know.

Born 1936
PSA 7.9, Gleason Score 3+4=7, 2 of 8 positive
open RP Nov 06, T3a, Gleasons 3+4=7, Seminal vesicles and lymph nodes clear
Catheter out 15 Dec 06, Dry since 11 Feb 07
All PSA tests in 2007 (4) <.04
PSA tests in 2008: Mar.=.04; Jun.=.05; Sept.=.08; 3 days before Rad Start=0.1, Salvage RT completed (33 days-66Gy) 19 Dec 08
PSA: in Jan 09 =.05, all tests to date <.04

Ed C. (Old67)
Veteran Member

Date Joined Jan 2009
Total Posts : 2461
   Posted 8/31/2010 11:31 AM (GMT -6)   
My pathology report says that the lymph nodes were not dissected. I asked my Uro for the reason and he said that they looked very smooth during the surgery and that because of my low PSA there was only a 3% chance of having lymph node metastases. With my high Gleason, I wish that he had sampled them. So far I've been blessed.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm in circumference.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 5 months
2 months PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1
8 months PSA test 10/9/09 result <0.1
11 months PSA test 1/21/10 result 0.004
14 months PSA test 4/19/10 result 0.005

AJ 47 (Maryland)
Regular Member

Date Joined Aug 2010
Total Posts : 64
   Posted 8/31/2010 11:54 AM (GMT -6)   
I had the same situation and was told that there are anatomical variances in the location of lymph nodes and that sometimes that are beyond the wide margin submitted for analysis.  I was told that nodes are palpated by the pathologist and are pushed out the fat and tissue manually before examination.  Sometimes the nodes are so small they cannot be identified by the pathologist.  I think it's clear they were not examined because they were not found.  According to my surgeon, if the wide margin in the area was clear, it is highly likely the nodes were clean too.  I don't know whether this is correct but it's what I was told.  Like Mel, they evaluated three nodes (all on the noncancerous side!).  Who knows.... 

Veteran Member

Date Joined Sep 2009
Total Posts : 3172
   Posted 8/31/2010 12:13 PM (GMT -6)   
AJ 47 said...
Who knows.... 
"Nx" means that the lymph node status is pathologically unknown.
The lymph node specimens would have been taken seperately from the prostate itself, so is therefore unrelated to the prostate's surgical margin.
A valid question to your surgeon after you received your surgical report would have been whether lymph nodes were taken (and why not, if his reply was "no").  Your surgery procedure report (different from your pathology report) may also give you a clue, and in fact after 7 months just about the only thing that your surgeon could do if you were to ask him about lymph nodes now would be to refer to his surgery procedure report to trigger his memory.
Do you get any clues from your surgery procedure report?

Veteran Member

Date Joined Jan 2010
Total Posts : 1011
   Posted 8/31/2010 3:58 PM (GMT -6)   
The surgery procedure report can be an interesting read. My surgeon told me that he spared both nerve bundles, yet the surgery procedure report says that he took out one. I was going to make a stink about it, but at the end of the day if it needed to be done then that's what I want.
Dx with PC Dec 2008 at 56, PSA 3.4

Biopsy: T1c, Geason 7 (3+4) - 8 cores taken with 4 positive for PCa, 30% of all 4 cores.

Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%
nerves spared, no negitive side effects of surgery

One night in hospital, back to work in 3 weeks

psa Jun 09 <.01
psa Oct 09 <.01
psa Jan 10 .07 re-test one week later .05
psa Mar 10 .28 re-test two weeks later .31
psa May 10 .50

April 10 MRI and Bone Scan show lesion on lower spine, false positive.

Started HT 5/25/10 with 3 month shot of Trelstar. SRT scheduled for late July

psa July 10 <.01 HT at work

Veteran Member

Date Joined Jul 2010
Total Posts : 3895
   Posted 8/31/2010 4:05 PM (GMT -6)   
I just got back from my pre-op visit with my surgeon. He stated that he clearly intends to remove some nearby lymph nodes...He also said that in my case he would take as wide a surgical margin as he could..Since the left side of my gland was clean, he said "maybe" he could spare that nerve bundle..
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third 12 core biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. I'm also looking at seeds combined with IGRT which seems to be having good results with high-risk patients..

Veteran Member

Date Joined Aug 2010
Total Posts : 644
   Posted 8/31/2010 5:08 PM (GMT -6)   
Thanks for all the info, people...

I had never heard of a surgery procedure report and will definitely ask for it.

I've put in a message to the doc to find out why no lymph node dissection, and haven't heard back yet.

I've also done some more reading and talking to others. Apparently most of the literature confirms that in intermediate and high risk cases (g7 or above, PSA>10, or palpable tumor) lymph nodes are supposed to be examined. But also, apparently it's harder to do lymph node dissection robotically than in the open RP and some surgeons who rarely do lymph node dissection or do it on a very limited basis when operating robotically. So I guess this is one more consideration to weigh when considering robotic vs. open, and one more thing to confirm with the doc pre-surgery.

thanks again...

Cajun Jeff
Veteran Member

Date Joined Mar 2009
Total Posts : 4119
   Posted 8/31/2010 5:14 PM (GMT -6)   
proscapt, My Dr told me that he favored open for that very reason. I did go with him on open surgery. Not positive that I made the right decision. Sometime I really wish I had danced with thr Robot. The little devil in my head keeps telling me "dummy if you had danced with the robot you would not have these ED issues. " I know that makes no sence but it still haunts me.

Cajun Jeff
9/08 PSA 5.4 referred to Urologist
9/08 Biopsy: GS 3+4=7 1 positive core in 12 1% cancer core
10/08 Nerve-Sparing open radicalSurgery Path Report Downgrade 3+3=6 GS Stage pT2c margins clea
r3 month: PSA <0.1
19th month: PSA <0.1
Only issue at this time is ED

Veteran Member

Date Joined Sep 2009
Total Posts : 3172
   Posted 8/31/2010 5:52 PM (GMT -6)   

Only conjecture on my part, but it is possible that you are mixing the resection of lymph nodes for post-surgical analysis with the inter-operational pathological examination of "frozen" lymph node specimens, which some doctors do, and some do not. Two different issues, but just to be clear, doctors performing robotic surgery can (and at least some do) perform lymph node resection for post-surgical analysis, and also they can send inter-operational lymph node specimens to the pathology lab before continuing with prostate removal (and at least some do, but less commonly).

However, bottom line is that I agree with you that it seems your case should have included lymph node resection. Again, I would guess that your surgery report holds clues.

Post Edited (Casey59) : 8/31/2010 4:57:40 PM (GMT-6)

Forum Moderator

Date Joined Jan 2010
Total Posts : 7087
   Posted 8/31/2010 5:57 PM (GMT -6)   
Referring to the surgical report - it came up for one of my fixed benefit insurance plans (required), and about the same time someone mentioned it here on the board.

So you might as well ask for a copy - if you have something along the lines of Aflac, they will want to see it to prove you got cut on.
My IGRT journey -

Veteran Member

Date Joined Aug 2010
Total Posts : 644
   Posted 8/31/2010 5:59 PM (GMT -6)   
Hi, everyone

Thanks to your encouragement to raise the issue with my surgeon, we just talked, and here's his explanation.

He said the problem with using simple protocols that stratify people into low, intermediate, and high risk is that the intermediate category is very broad and so if you use only a three tier system you over-treat some people and under-treat others.

As a result, he said that they (at UCSF) us a system called CAPRA to stage the patients headed for RP. Capra is a 1-10 scoring system. It's similar to the Kattan nomogram but it has two key advantages (1) it's simpler to calculate and interpret, so you don't need a paper form or computer, and (2) it's based on data from patients treated in the community so it's a little more accurate (less optimistic) relative to Kattan for the lowest risk patients treated in the community. It's been well validated, and you can read about it here:

By the CAPRA system, my score is on the low side of 3 (on a scale of 1-10) which puts me in the lowest rung of intermediate cancers, and for this score, the risk of lymph node involvement is only 2.4%. So at that level, and given that there is some morbidity associated with lymph node dissection, their protocol is not to dissect lymph nodes. Whether or not you agree with that decision is a question, but at least I have the satisfaction of knowing that the decision was based on sound science, and not just an oversight in the OR or the path lab.

With the URL above you can go calculate your own scores, or you can use the online calculators at MSKCC. I did it both ways, and the results are quite close.

thanks again for your suggestions and encouragement.

Post Edited (proscapt) : 8/31/2010 5:26:01 PM (GMT-6)

Veteran Member

Date Joined Jan 2010
Total Posts : 2845
   Posted 8/31/2010 7:23 PM (GMT -6)   
- thanks for introducing us to the CAPRA system ( loved his movies - :-) )
- did the test and ended up with score of 6 - high risk prostate cancer
- my doc removed the lymph nodes as part of procedure as outlined by Casey59 - to verify prostate cancer is still contained - and the removal of the prostate operation continued.

-wishing you all the best

Age: 54 -gay with spouse, Steve - live in Peteborough, Ontario, Canada
PSA: 10/06/2009 - 3.86
Biopsy: 10/16/2009- 6 of 12 cancerous samples, Gleason 7 (4+3)
Radical Prostatectomy: 11/18/2009
Pathology: pT3a- gleason 7 -extraprostatic extension -perineural invasion -prostate weight -34.1 gm
Post Surgery-PSA: April 8, 2010 - 0.05 -I am in the ZERO CLUB - hooorah!
Next PSA: Sept 23, 2010 -TBA
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