EPE in Second Opinion Path Report

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RickTrin
Regular Member


Date Joined Nov 2015
Total Posts : 69
   Posted 9/11/2017 1:22 PM (GMT -7)   
I had RRP surgery about three weeks ago on 8/16 at Mass General in Boston. The pathology report was negative for SV, LN, margins and EPE. The final Gleason was 3+4=7 vs. my three prior biopsies (see signature below) which never showed anything other than Gleason 6. Given the upgrade, I wanted to know what percent was pattern 4. That was not provided in the Mass General report, so I had the slides sent to John Hopkins for a second reading and to get the percentage amount for pattern 4.

What came back from the JH reading was that the pattern 4 was 10%. The JH reading was the same as Mass General with negative margins, SV and LN, however, they did identify positive EPE whereas MG showed that as negative.

Given this I have a few questions - How subjective are these EPE opinions? How significant is positive EPE relative to negative margins? Is there anything I should do other than wait for first post surgery PSA test which is scheduled three months from surgery?
Age 56
PSA 3.9=>7.4 2012-2016
5/13-1st biopsy 1 of 14 cores G6 at <1%; 7/13-1st mpMRI all clear
4/14-2nd biopsy 1 of 17 cores G6 at 5%; 8/15-2nd mpMRI all clear
4/17-3rd mpMRI one 19mm PIRADS 4 lesion in transition zone
5/17 - fusion biopsy 5 of 21 cores G6 at 20% to 90%; all 5 positive in target TZ lesion, 16 other benign
8/17 - RRP Surgery, pT2c margins-, EPE-, SV-, LN- Gleason 3+4=7

Gemlin
Veteran Member


Date Joined Jul 2015
Total Posts : 604
   Posted 9/11/2017 2:00 PM (GMT -7)   
Where was the EPE? If it was at the apex there is no reliable diagnose about it, so yes, it is very subjective, I would say. Anyway with negative margins you do not need ART so don't think to much about it, just focus on your recovery. Have you started penile recovery yet?
Age at detection: 60
PSA 4.1 2014-02-25
Biopsy 2014-04-24, 4 of 10 cores positive, G: 3+4,4+3,4+3 EPE,4+3. PNI+
Bone scan negative
DaVinci 2014-08-31, nerve sparing right side
Prostate 35 g, 46x37x38 mm
Tumor dorsal PZ, SV-, 14 LN-, SM-, pT3a, G7 (4+3), EPE+ left side
PSA:
2014-10 <0.05
2015-03 <0.05
2015-09 <0.05
2016-03 <0.05
2016-09 <0.05
2017-09 <0.1

RickTrin
Regular Member


Date Joined Nov 2015
Total Posts : 69
   Posted 9/11/2017 2:16 PM (GMT -7)   
Thanks Gemlin

The EPE was the right base. The biopsies never found much of anything (2 out 47 cores <5% G6) other than the fusion biopsy which went 5 for 5 at the target 19mm lesion (from mpMRI) in my transition zone. I'm guessing this same nodule is the one in question with EPE.

My recovery has gone well. Never had much pain or even fatigue. My cath came out two weeks ago today and the incontinence is fading. Always dry at night and through most of the day until the afternoon. For some reason, I get some leaking from 3-6pm then it stops for rest of evening. For past few days, even 3-6pm leaking seems to be going away.

As for ED, for a week now, I've been taking 5 mg of Cialis every other day and then over the weekend took a full 20 mg dose which led to a little firmness (though not much) with stimulation. I'm supposed to keep taking the 5 mg every other day with a full dose once a week.
Age 56
PSA 3.9=>7.4 2012-2016
5/13-1st biopsy 1 of 14 cores G6 at <1%; 7/13-1st mpMRI all clear
4/14-2nd biopsy 1 of 17 cores G6 at 5%; 8/15-2nd mpMRI all clear
4/17-3rd mpMRI one 19mm PIRADS 4 lesion in transition zone
5/17 - fusion biopsy 5 of 21 cores G6 at 20% to 90%; all 5 positive in target TZ lesion, 16 other benign
8/17 - RRP Surgery, pT2c margins-, EPE-, SV-, LN- Gleason 3+4=7

RickTrin
Regular Member


Date Joined Nov 2015
Total Posts : 69
   Posted 9/11/2017 4:43 PM (GMT -7)   
Just from some quick online reading, it seems as though there's some question about whether or not EPE alone with negative margins needs treatment?
Age 56
PSA 3.9=>7.4 2012-2016
5/13-1st biopsy 1 of 14 cores G6 at <1%; 7/13-1st mpMRI all clear
4/14-2nd biopsy 1 of 17 cores G6 at 5%; 8/15-2nd mpMRI all clear
4/17-3rd mpMRI one 19mm PIRADS 4 lesion in transition zone
5/17 - fusion biopsy 5 of 21 cores G6 at 20% to 90%; all 5 positive in target TZ lesion, 16 other benign
8/17 - RRP Surgery, pT2c margins-, EPE-, SV-, LN- Gleason 3+4=7

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8817
   Posted 9/11/2017 7:17 PM (GMT -7)   
There's no question about it - at least not in my mind. Wait for the 3 month uPSA.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

RickTrin
Regular Member


Date Joined Nov 2015
Total Posts : 69
   Posted 9/12/2017 12:42 AM (GMT -7)   
I'm pretty shocked by this finding -- 1) I've had three biopsies that only ever found small amounts of G6 around the prostate and three mpMRIs two of which were totally clear and all three showed no EPE and 2) this seems like a big miss by mass general in their final pathology. How does that happen?

Now I'm wondering if spending 4.5 years on AS was a mistake.
Age 56
PSA 3.9=>7.4 2012-2016
5/13-1st biopsy 1 of 14 cores G6 at <1%; 7/13-1st mpMRI all clear
4/14-2nd biopsy 1 of 17 cores G6 at 5%; 8/15-2nd mpMRI all clear
4/17-3rd mpMRI one 19mm PIRADS 4 lesion in transition zone
5/17 - fusion biopsy 5 of 21 cores G6 at 20% to 90%; all 5 positive in target TZ lesion, 16 other benign
8/17 - RRP Surgery, pT2c margins-, EPE-, SV-, LN- Gleason 3+4=7

Gemlin
Veteran Member


Date Joined Jul 2015
Total Posts : 604
   Posted 9/12/2017 4:58 AM (GMT -7)   
False negative rate of one prostate biopsy could be something like 30% and it will underestimate the Gleason scores in almost 50%!!
But you had three biopsies so the false negative rate in your case was only 2.7% (30% x 30% x 30% = 2.7%) and underestimated Gleason was 12.5 %.

This simple math is the reason why repeated biopsies is so important in AS programs.

BTW, your pathology report is great, better than mine was.
Age at detection: 60
PSA 4.1 2014-02-25
Biopsy 2014-04-24, 4 of 10 cores positive, G: 3+4,4+3,4+3 EPE,4+3. PNI+
Bone scan negative
DaVinci 2014-08-31, nerve sparing right side
Prostate 35 g, 46x37x38 mm
Tumor dorsal PZ, SV-, 14 LN-, SM-, pT3a, G7 (4+3), EPE+ left side
PSA:
2014-10 <0.05
2015-03 <0.05
2015-09 <0.05
2016-03 <0.05
2016-09 <0.05
2017-09 <0.1

RickTrin
Regular Member


Date Joined Nov 2015
Total Posts : 69
   Posted 9/13/2017 8:50 AM (GMT -7)   
I actually spoke with Dr. Epstein about the second opinion of EPE. Its great that he makes himself available.

He said the EPE was small (presumably why Mass General missed it). He also said given my low Gleason score (3+4, with only 10% pattern 4 involvement) and negative margins, I shouldn't worry too much about this. Certainly nothing to do until after first PSA three months out.
Age 56
PSA 3.9=>7.4 2012-2016
5/13-1st biopsy 1 of 14 cores G6 at <1%; 7/13-1st mpMRI all clear
4/14-2nd biopsy 1 of 17 cores G6 at 5%; 8/15-2nd mpMRI all clear
4/17-3rd mpMRI one 19mm PIRADS 4 lesion in transition zone
5/17 - fusion biopsy 5 of 21 cores G6 at 20% to 90%; all 5 positive in target TZ lesion, 16 other benign
8/17 - RRP Surgery, pT2c margins-, EPE-, SV-, LN- Gleason 3+4=7

InTheShop
Veteran Member


Date Joined Jan 2012
Total Posts : 7924
   Posted 9/13/2017 12:43 PM (GMT -7)   
waiting is hard.

The three month PSA is what you really need.

Take some time off from PC and wait for the test.
Andrew
I'll be in the shop.
Age 57, 52 at DX
PSA:
4.2 10/11, 1.9 6/12, 1.2 12/12, 1.0 5/13, .6 11/13,
.7 5/14, .5 10/14, .5 4/15, .3 10/15, .3 4/16, .4 10/16, .4 5/17
G 3+4
Stage T1C
2 out of 14 cores positive
Treatment IGRT - 2/2012
My latest blog post

RickTrin
Regular Member


Date Joined Nov 2015
Total Posts : 69
   Posted 9/13/2017 1:24 PM (GMT -7)   
Thanks and good advice.

One benefit of being on AS for 4+ years, is that you become more practiced in waiting for results -- biopsies, MRI's, PSAs, etc. I've definitely gotten better at being able to largely forget about PC in between new data points. Once new data is in, do research, with this site being a fantastic resource, figure out my odds, make a decision and then move on until the next data/decision point. Its not always that easy, but AS actually helped me get better at it.
Age 56
PSA 3.9=>7.4 2012-2016
5/13-1st biopsy 1 of 14 cores G6 at <1%; 7/13-1st mpMRI all clear
4/14-2nd biopsy 1 of 17 cores G6 at 5%; 8/15-2nd mpMRI all clear
4/17-3rd mpMRI one 19mm PIRADS 4 lesion in transition zone
5/17 - fusion biopsy 5 of 21 cores G6 at 20% to 90%; all 5 positive in target TZ lesion, 16 other benign
8/17 - RRP Surgery, pT2c margins-, EPE-, SV-, LN- Gleason 3+4=7
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