I had my 19 month check-up with Dr. Ash Tewari last week. He made one major "upgrade" since moving to Mt. Sinai: As soon as the prostate is removed, it is rushed to pathology while the patient is still on the operating table. Pathology folks inspect the entire surface of the prostate for cancer cells. If there are any positive margins, that info is relayed to Dr. Tewari within minutes so he can remove more tissue in that area and hopefully remove any remaining cancer.
Is anyone aware of other surgeons who get real-time pathology of the full prostate surface during surgery?
(When I had my surgery with Dr. Tewari at NY Presbyterian, only a few tissue samples were sent to Pathology during the surgery.)
This is an interesting historical evolution of the frozen section process. History lesson:
Twenty years ago or more, in the pre-robotic surgery days, there were still many men presenting with advanced disease, and the imaging tools were not as sophisticated or “good” as they are today. Back then, when a surgeon
opened up a patient, he more frequently found “surprises” such regional metastasis to lymph nodes (LNs). The practice then became to look first at LNs and resect (remove) several before even touching the prostate; the procedure was “on-hold” until those results were called into the OR. The LNs were rushed to pathology, and if cancer was found, then the patient was closed-up without the removal of the cancerous prostate; the point being that since there was already regional spread, the surgery wasn’t going to solve the problem, and the better thing for the patient was to minimize the trauma/side effects and send the patient promptly to radiation therapy.
Next came robotic prostatectomies. Robots are super expensive tools which the hospital seeks to maximize utilization of, and the intraoperative frozen LN sectioning became basically vetoed by the hospital operations management team…took too much time. That turned out to be not bad because it coincided with the dramatic shift from men presenting with advanced cases to the majority presenting with smaller-and-smaller cases of less advanced or even benign PC, so far fewer cases with regional spread.
Today, mpMRI has emerged as a pre-operative tool to help guide the surgeons to maximize the opportunities for nerve-sparing procedures while minimizing the possibilities for positive surgical margins; surgeons use mpMRI results in the decision making process to select a nerve-sparing approach.
But time is still money in the operating room equipped with a multi-million dollar robot, but necessity is the mother of invention. Recent innovations have recently been marketed to assist in the rapid resection/extraction of the prostate into a nifty package ready to be taken to pathology in the next room…it’s been marketed as “easy and fast,” and today adds only about
10 minutes to the total OR time (which is still a controversial consumption of resources in many hospitals).
Oncological outcomes have been demonstrated to be improved for patients with higher Gleason scores. (Low Gleason score are not impacted, as they didn’t need surgery anyhow.) The improved oncological outcomes are achieved by secondary resection, or re-resection, or simply “going back for more.” This typically happens in the difficult-to-reach bladder neck area.
It’s not perfect…there were still patients who were declared to have negative margins of their frozen sections during surgery but did, indeed, have PSMs at final pathology. But that was outweighed by the higher number of patients who were found to have PSM of their frozen section but no issues afterward. The final pathology is still the gold standard for margin status analysis.