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Post prostatectomy pathology report.

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User
Posted 03 Oct 2024 at 09:09

Morning lads and lasses.

I found this video today. I found it beautifully clear and informative. I thought it might be useful to others.

https://youtu.be/-rH-P7Fx_zc?si=HZYdG8sX9_4LHwll

 

User
Posted 03 Oct 2024 at 19:56

Originally Posted by: Online Community Member

Bloomin eck! It's complicated. I'll always remember after my second biopsy, how the surgeon kept emphasising the fact that 20 out of 24 cores were positive. He seemed more bothered about that than anything else. I've had so many cancer stages in two years, varying from T1c, T2a, T2c to T3a. I've had Gleason scores varying from Gleason 6(3+3) in my first biopsy, in my second biopsy there were areas of Gleason 7(3+4), 7 (4+3) and 8 (3+5). On some of my records they clumped these together as 8 (4+4) but on the actual biopsy report it was recorded as 8 (3+5). The final score of the removed prostate was 9 (4+5). I'm beginning to think they got my Gleason scores by rolling a pair of dice. 😁

 On my second biopsy report, they commented that after my first biopsy records showed me as Gleason 6+6!  which they amended to Gleason 6. They must have thrown a double six and had another go? 😂

 

I genuinely love Adrian's posts. We all, almost cetrtainly go through the same uncertaintities. But few come through on here with the same hope and conviction as our Adrian.

Cheers brother.

 

Jamie.

 

 

User
Posted 04 Oct 2024 at 11:01

I vaguely remember reading somewhere that, at the biopsy stage, if there are cores with different Gleason scores, they use the worst one for the summary diagnosis.

I am not sure what the logic of this would be but perhaps it is because at least some of the biopsy is random so they don't know if that worst bit is just a section of  a larger area of bad stuff and so they err on the side of caution.

I don't think they do that with the post-op pathology because they then have the whole prostate to look at (but again, that is my impression - I am not sure of it).

Hopefully somebody will be able to give a more definitive answer.

User
Posted 04 Oct 2024 at 11:34

The pathology from a removed prostate certainly looks at more of it than a biopsy can, but it's still a very long way from looking at all of it - typically it's about 6 surface slices though it. This still misses some positive margins which are only in between the slices.

At some places (such as Guildford I know specifically), you may be asked if you would donate your prostate to research. Some of these are fully microtomed (sliced into many hundreds of slices) by the researchers who are tracking the cancer in much more detail to build accurate 3D images. However, I don't know if the researchers can feed back any more detail than the original pathology did.

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User
Posted 03 Oct 2024 at 11:41

That is a good video, but I really would like a better definition of:

T4, Stage 4, M1 and Spread.

He discusses what I would call N1 and he calls this Spread. 

As I understand it, when the letter T is involved it is talking about the tumour (and I'm going to assume that means the primary tumour). I understand T4 to mean the primary tumour has grown beyond the prostate and into a neighbouring organ (bladder, rectum). If it has grown beyond the prostate but not into a neighbouring organ it is still T3.

So I think it is possible to be T4N0M0 and though this would not lend itself to surgery, it is potentially curable with RT.

Now I think N1 and M1 both require secondary tumours in either the lymph nodes or any other tissue.

So I think it would be possible to be T1N1M1 i.e. a tumour only observable by scans in the prostate but already secondary tumours elsewhere.

"Spread" I can accept as a colloquial word for anything beyond T4 or N1 or M1.

"Stage4" seems to be used in the same way as I have defined spread. So could include T1,T2 or T3 if the N or M is 1.

If I am wrong in thinking the T relates to the primary tumour and relates to any tumour in the body, then a diagnosis of T3N1 would be impossible: as T3 is contained, but N1 implies T4. Thus once N or M are 1, T has to be 4.

Sorry this post sounds like a mathematical treatise on set theory. I really hope someone can clarify this.

Dave

User
Posted 03 Oct 2024 at 16:43

This is confusing with prostate cancer because the TNM staging doesn't match the cancer Stage.

T4 means the original tumour (and not mets) has grown out of the prostate into another organ (such as bladder, rectum, pelvic floor - that's about all that's near enough), but T4 excludes the case of growing only into the seminal vesicles, which is T3b.

Stage IV (or advanced) means you have mets outside the prostate, seminal vesicles, and pelvic lymph nodes.

N1 is pelvic lymph nodes. Any more distant lymph nodes would be M1a.

I think Stage IV was originally intended to mean incurable, but what's curable (or at least, eligible for a curative treatment) has changed considerably in recent years. One or two small bone mets (M1b) is now curable in some cases, but I'm not sure anyone has changed the definition of Stage IV on that basis.

T4N0M0 is Stage III (locally advanced), not Stage IV (advanced).
Yes, T4NxM0 would be treated with radiotherapy. In some cases, surgery to repair bladder or bowel might also be required.

Spread doesn't have any recognised medical definition. It might be applied to anything more than T2cN0M0, but it will depend on the context.

Edited by member 03 Oct 2024 at 16:48  | Reason: Not specified

User
Posted 03 Oct 2024 at 17:52

Hi Dave

I'm not a doctor but since my diagnosis with prostate cancer in June I've read up a lot on the subject.

The N as you correctly pointed out refers to cancer cells in the nearby lymph nodes. The primary tumour does not have to break out of the prostate capsule to infect these as cancer cells can break off and float around in the blood or lymphatic system. The link to a very informative video is below. At timepoints 14 mins the narrator talks about how cancer cells can spread. His dandelion analogy is interesting. You can also switch on cc for subtitles.

https://www.youtube.com/watch?v=x9FGleZAieo 

Hope it helps.

Len

Edited by member 03 Oct 2024 at 18:08  | Reason: Not specified

User
Posted 03 Oct 2024 at 18:44

Bloomin eck! It's complicated. I'll always remember after my second biopsy, how the surgeon kept emphasising the fact that 20 out of 24 cores were positive. He seemed more bothered about that than anything else. I've had so many cancer stages in two years, varying from T1c, T2a, T2c to T3a. I've had Gleason scores varying from Gleason 6(3+3) in my first biopsy, in my second biopsy there were areas of Gleason 7(3+4), 7 (4+3) and 8 (3+5). On some of my records they clumped these together as 8 (4+4) but on the actual biopsy report it was recorded as 8 (3+5). The final score of the removed prostate was 9 (4+5). I'm beginning to think they got my Gleason scores by rolling a pair of dice. 😁

 On my second biopsy report, they commented that after my first biopsy records showed me as Gleason 6+6!  which they amended to Gleason 6. They must have thrown a double six and had another go? 😂

 

Edited by member 03 Oct 2024 at 19:05  | Reason: Typo

User
Posted 03 Oct 2024 at 19:48

Thanks everybody. My MRI said "T3 with extra prostatic extension and no seminal vascular involvement". I now know this could have just said "T3a", maybe the radiographer was paid by the word. Using the word "stage" for Tstage and AJJC stage, is likely to cause confusion.

Dave

User
Posted 03 Oct 2024 at 19:56

Originally Posted by: Online Community Member

Bloomin eck! It's complicated. I'll always remember after my second biopsy, how the surgeon kept emphasising the fact that 20 out of 24 cores were positive. He seemed more bothered about that than anything else. I've had so many cancer stages in two years, varying from T1c, T2a, T2c to T3a. I've had Gleason scores varying from Gleason 6(3+3) in my first biopsy, in my second biopsy there were areas of Gleason 7(3+4), 7 (4+3) and 8 (3+5). On some of my records they clumped these together as 8 (4+4) but on the actual biopsy report it was recorded as 8 (3+5). The final score of the removed prostate was 9 (4+5). I'm beginning to think they got my Gleason scores by rolling a pair of dice. 😁

 On my second biopsy report, they commented that after my first biopsy records showed me as Gleason 6+6!  which they amended to Gleason 6. They must have thrown a double six and had another go? 😂

 

I genuinely love Adrian's posts. We all, almost cetrtainly go through the same uncertaintities. But few come through on here with the same hope and conviction as our Adrian.

Cheers brother.

 

Jamie.

 

 

User
Posted 04 Oct 2024 at 10:24

This conversation has made me recheck my second biopsy report.

I shall give as much detail as I can because I'm hoping someone can answer questions, I have about it. 

The biopsy was done under GA. It was MRI targeted to a lesion in the left lobe and a lesion in the right lobe. Histological diagnosis Adenocarcinoma.

Left targeted area. 6 cores, longest 19mm, modified Gleason 7 (3+4), 6 out of 6 cores containing tumour. Total percentage of cancer 50% Microscopic features not present.

Left random. 6 cores, longest 20mm, modified Gleason 8 (3+5), 5 out of 6 cores containing tumour,  total percentage of cancer 40%. Microscopic features not present. One of the cores contains malignant glands with comedonecrosis. Hence this is judged Gleason pattern 5.

Right targeted area. 6 cores, longest 21mm, modified Gleason 7 (4+3), 5 out of 6 cores containing tumour, total percentage of cancer 25%. Microscopic features not present.

Right random. 6 cores , longest 19mm, modified Gleason 7 (4+3), 4 out of 6 cores containing tumour, total percentage of cancer 25%. Microscopic features not present.

Overall modified Gleason score 8 (3+5)

Summary: Adenocarcinoma, Gleason 8 (3+5), Grade group 4, involving 20 out of 24 cores.

The questions I have are.

A. How, when there are so many Gleason variations do they decide on the overall score?

B. I've researched comedonecrosis. It's not good news and appears to be extra aggressive, making BCR more likely.  It was only found in one core but has seemed to upped all the cores in the area where it was found to 3+5. Leading to an overall 3+5 score. I don't understand why?

C. What in each area does the total percentage of cancer refer to? Does it refer to how much cancer was in the cores. Or does it mean what percentage of the cancer was at a specific Gleason score.

D. Each area says no microscopic features present. Yet they found comedonecrosis which I presume is a microscopic feature?

I'm hoping answers to my questions will also help others with the terminology of biopsy reports and understanding them better.

When we've cleared up these queries. I'll move onto the post op biopsy, which contains terms that also confuse me.

I bet you can't wait. 🙂

Cheers.

Edited by member 04 Oct 2024 at 10:35  | Reason: Additional text

User
Posted 04 Oct 2024 at 11:01

I vaguely remember reading somewhere that, at the biopsy stage, if there are cores with different Gleason scores, they use the worst one for the summary diagnosis.

I am not sure what the logic of this would be but perhaps it is because at least some of the biopsy is random so they don't know if that worst bit is just a section of  a larger area of bad stuff and so they err on the side of caution.

I don't think they do that with the post-op pathology because they then have the whole prostate to look at (but again, that is my impression - I am not sure of it).

Hopefully somebody will be able to give a more definitive answer.

User
Posted 04 Oct 2024 at 11:34

The pathology from a removed prostate certainly looks at more of it than a biopsy can, but it's still a very long way from looking at all of it - typically it's about 6 surface slices though it. This still misses some positive margins which are only in between the slices.

At some places (such as Guildford I know specifically), you may be asked if you would donate your prostate to research. Some of these are fully microtomed (sliced into many hundreds of slices) by the researchers who are tracking the cancer in much more detail to build accurate 3D images. However, I don't know if the researchers can feed back any more detail than the original pathology did.

User
Posted 04 Oct 2024 at 14:25

It's all a bit of a mystery really to be honest. I was T3a, Gleason 7 (3+4),  TGP5 found in one side, and Cribriform in the other. Everything I've read tells me that with these results, I am at a high risk of BCR. My surgeon however, maintains that the risk is maximum 10% within 10 years. You don't know who to believe.

User
Posted 04 Oct 2024 at 14:43

If you really want to frighten yourself try a nonogram.

https://www.mskcc.org/nomograms/prostate/post_op

It told me I've got more chance of  winning the lottery jackpot than avoiding BCR. 🙂

 

Edited by member 04 Oct 2024 at 15:20  | Reason: Typo

User
Posted 05 Oct 2024 at 00:12

Originally Posted by: Online Community Member

If you really want to frighten yourself try a nonogram.

https://www.mskcc.org/nomograms/prostate/post_op

It told me I've got more chance of  winning the lottery jackpot than avoiding BCR. 🙂

 

 

Don't do that. Because yes, you WILL frighten yourself 😱! After my biopsy, I plugged my numbers into that nomogram and it told me that with surgery I had a 90% chance of recurrence within 10 years. At my staging of T3a I recognize my chances of recurrence (following RP) are high, but 90%?? Even as I am a pessimist, from what my surgeon said, and from my own research I think that number is exaggerated. That being said, as I sit here typing this, I am currently awaiting the results from my first post surgery PSA test (blood taken yesterday) and I am brick'n it big time!

 

Back on the subject of Gleason variance, I can also add that my pre-surgery biopsy was mostly 4+3 and 3+4, but 2 cores pulled 4+5 with cribriform. Then, my post RP histology report graded me as 4+3. It did not find any G5 nor was there any mention of cribriform. I don't understand how 2 random needles could find one thing, but an analysis of the entire tissue sample comes back as something completely different.

User
Posted 05 Oct 2024 at 08:16

Hi Mike

I was T3a with EPE and Gleason 9 (4+5) and my PSA was 6.6. 18 months post op my PSA has been undetectable. The nonogram worked my chances of being BCR free as: after 5 years 60%, after 7 years as 49% and after 38% after 10 years.

I'd have thought, even though as yet, you haven't got any BCR free months to input into the nonogram, that your chances of being long term BCR free are better than mine as I had a worse Gleason and EPE. 

It was great news that your post op showed no Gleason 5. As you say the variation of pre op and post op biopsies are slightly mystifying. I believe most post op histology result in more upgrades to the Gleason score than down grades.

Here is some recent research into BCR post surgery and factors that increase the chances of recurrence.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815528/#:~:text=Radical%20prostatectomy%20(RP)%20remains%20the,RP%20(2%2D4).

Very best of luck with your first post op PSA.

 

Edited by member 05 Oct 2024 at 08:34  | Reason: Additional text

User
Posted 05 Oct 2024 at 10:23

My Husbands biospy revealed a single left sided tumour of Gleeson 4+5 from a single area mid left! Stage 2b It said the cancer was very close to the edge of capsule 
The pathology found cancer on both sides of the prostate (despite having six cores on the biospy from the right and not getting any cancer) The Gleeson was still 4+5 but it said there was only a single cell of pattern 5 found! This is very hard to believe that biopsy hit the single cell aswell as the pathologist! The consultant said could almost be a Gleeson 8! I find that hard to believe as the biospy and the pathology could have hit different areas? Although I have since read that the awarding of Gleeson number could be subjective to the person reading the pathology so one person 4 could be another persons 5? Is that correct? 
M 

 
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