Please Help Explain Results Please help explain Pathology report after Davinci Radical Prostatectomy w/ Extended Lymph Node Dissection

[Shorehousejam]

Please help explain Pathology report after Davinci Radical Prostatectomy w/ Extended Lymph Node Dissection

Diagnosed 07/2022 PSA 964.40 Gleason 8 4+4 Ductal Subtype Cribform Architecture

Had / Currently Triplicate Therapy

Firmagon @28 days

Zytiga Daily Prednisone 5mg

Metformin 500mg daily, for raised glucose by primary doctor at our suggestion

Docetaxel Chemotherapy @6 sessions

Davinci Radical Prostatectomy with extended lymph node dissection

Sent Home within hours

Thank God No Complications

Catheter for 7 days

Removed

Light leakage otherwise ok

——-

Pathology from Surgery March 14th 2023

GBG OPERATING ROOM

Age/Sex: 61 / M

CLINICAL INFORMATION:

Prostate cancer (C61). Per EPIC: Status post chemotherapy.

CANCER SYNOPSIS:

PROSTATE GLAND

I. PROCEDURE: Radical prostatectomy

II. HISTOLOGIC TYPE: Acinar

adenocarcinoma

III. HISTOLOGIC GRADE: Grade Group 4 (Gleason score: 4+4=8)

IV. PATHOLOGIC STAGE CLASSIFICATION (pTNM, AJCC 8th Edition):

y(post treatment)

pT3a: Extraprostatic extension (unilateral or bilateral) or microscopic invasion of bladder neck

pN0: No regional lymph node metastasis

V. REGIONAL LYMPH NODES:

Number of Lymph Nodes Involved: 0

Number of lymph nodes examined: 8

VI. MARGINS:

Involved by invasive carcinoma; non-limited (=3 mm)

Location of positive margin: Bladder neck

VII. TUMOR QUANTITATION: Low volume (<5%)

VIII. SEMINAL VESICLE INVASION: Cannot be assessed

IX. EXTRAPROSTATIC EXTENSION: Present, nonfocal

X. URINARY BLADDER NECK INVASION: Present

XI. TREATMENT EFFECT: Chemotherapy effect present in benign prostatic tissue.

DIAGNOSIS:

A. Prostate and pelvic lymph nodes; radical prostatectomy with lymphadenectomy:

Prostatic adenocarcinoma, Grade Group 4 (Gleason score 4+4=8) with ductal features.

Residential tumor predominantly involves th

e left anterior and posterior base.

Extablished extraprostatic extension is present in the bladder neck / base.

Tumor is present at the left bladder neck margin.

Length of positive margin: at least 6 mm; Gleason score at margin: 4+4=8.

No angiolymphatic invasion identified.

All other surgical margins are negative for tumor.

Uninvolved prostate with areas of dense fibrosis and hemosiderin-laden macrophage infiltration, consistent with areas of tumor regression.

Eight lymph nodes are negative for metastatic carcinoma (0/8).

One lymph node shows changes consistent with treatment effect (i.e. tumor regression); no viable tumor is identified.

Comment: Case reviewed at the Daily Departmental Consensus Conference with agreement on the above diagnosis.

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GROSS DESCRIPTION:A. Received fresh, the specimen is labeled "prostate and pelvic lymph nodes", and consists of a 20.95 gram prostatectomy specimen including a 4.3 x 3.6 x 3.1 cm prostate and a 7.4 x 4.3 x 1.8 cm aggregate of lymph nodes and fibroadipose tissue. The seminal vesicles and vas deferentia are not grossly identified. The right side of the specimen is inked green and the left side is inked black. The bladder neck and apical margins are shaved and submitted. The prostate is serially sectioned from the apex to base with sections designated from A to D respectively. On sectioning, multiple nodular and cystic areas are seen. Slice C of the prostate submitted for potential ancillary study. The remaining prostate is submitted entirely. Summary of sections: A1-right anterior base, A2-right posterior base, A3-left anterior base, A4-left posterior base, A5- anterior apex, A6- posterior apex, A7-ARA, A8-ARP, A9-ALA, A10-ALP, A11-BRA, A12-BRP, A13-BLA, A14-BLP, A15-DRA, A16-DRP, A17-DLA, A18-DLP, A19-one lymph node, bisected, A20- one lymph node, bisected, A21-A23- one lymph node, quadrisected, A24-A25-one lymph node, quadrisected, A26- remaining fibroadipose tissue. (CRS)

[Justfor_]

Some points:

1) "Extended" lymphadenectomy with 8 lymph nodes is kind of American English for us Europeans. I had 20 lymph nodes resected and still don't qualify for the "extended" group. I know that in the US the numbers are way far lower, but over here "extended" means +/-30 nodes.

2) The first thing that the pathology report should had documented is the volume and/or weight of the prostate. With your very high pre-surgery PSA the size of the gland plays an important role in evaluating the malignancy spread.

3) "SEMINAL VESICLE INVASION: Cannot be assessed"? Does this mean that seminal vesicles were left un-resected? If yes, they can be one of the weakest spots for recurrence.

4) "Residential tumor predominantly involves the left anterior and posterior base. Established extraprostatic extension is present in the bladder neck / base." Topologicaly, the prostate base and the bladder neck are very close together. This sentence is the least positive in the report IMO.

[Shorehousejam in reply to Justfor_]

We are going to ask for another evaluation of pathology

[Justfor_ in reply to Shorehousejam]

It seems the right thing to do. You could also ask for a copy of the report of the surgical procedure. It used to be compiled by the surgeon's assistant, but with the advent of the robotic machines this was upgraded to video recording the entire procedure for archival purposes.

[Shorehousejam in reply to Justfor_]

We spoke to pathology his seminal vessels are missing or not able to see them

[Justfor_ in reply to Shorehousejam]

Two different things:

1) Resected (taken out) and afterwards missing, is lost of important information.

2) Un-resected (left behind), explaining why they were missing from the pathologist's review, is a matter of concern for possible future recurrence.

[Shorehousejam in reply to Justfor_]

They were removed per surgical report and were “ not in jar” per pathologist

[Shorehousejam in reply to Justfor_]

look what was added

GROSS DESCRIPTION:A. Received fresh, the specimen is labeled "prostate and pelvic lymph nodes", and consists of a 20.95 gram prostatectomy specimen including a 4.3 x 3.6 x 3.1 cm prostate and a 7.4 x 4.3 x 1.8 cm aggregate of lymph nodes and fibroadipose tissue. The seminal vesicles and vas deferentia are not grossly identified. The right side of the specimen is inked green and the left side is inked black. The bladder neck and apical margins are shaved and submitted. The prostate is serially sectioned from the apex to base with sections designated from A to D respectively. On sectioning, multiple nodular and cystic areas are seen. Slice C of the prostate submitted for potential ancillary study. The remaining prostate is submitted entirely. Summary of sections: A1-right anterior base, A2-right posterior base, A3-left anterior base, A4-left posterior base, A5- anterior apex, A6- posterior apex, A7-ARA, A8-ARP, A9-ALA, A10-ALP, A11-BRA, A12-BRP, A13-BLA, A14-BLP, A15-DRA, A16-DRP, A17-DLA, A18-DLP, A19-one lymph node, bisected, A20- one lymph node, bisected, A21-A23- one lymph node, quadrisected, A24-A25-one lymph node, quadrisected, A26- remaining fibroadipose tissue. (CRS)

[Justfor_ in reply to Shorehousejam]

There is the long shot that the hormonal treatment that preceded shrunk them to such an extent that the pathologist just overlooked them. Such a heavy per-treatment that your husband had before surgery could fool the average pathologist dealing almost 100% with naive prostates.

[Shorehousejam in reply to Justfor_]

the surgeon is one of the best there is, internationally known….it’s the pathology report that is lacking clarity

[Justfor_]

Sorry, no comment. On the practical side of things at the next MRI, whenever that may be, you can ask the radiologist to confirm the surgical report.

[Shorehousejam in reply to Justfor_]

lol this is just unbelievable

[Tall_Allen]

The prostatectomy post docetaxel and Zytiga is for debulking purposes. It shows extensive ductal cancer at the base and invasion of the nearby bladder neck, where there is a positive margin. No active cancer in the lymph nodes removed, just some dead cancer there. Seminal vesicles are missing, but they were removed.

[Shorehousejam in reply to Tall_Allen]

It was a Davinci Radical Prostatectomy with lymph node removal, isn’t debunking just part of the prostate?

The pathologist can not decipher the seminal vessels from other tissue so the only cancer was in the bladder neck

The pathology is p3TA

So is this bad?

[Tall_Allen in reply to Shorehousejam]

Debulking means removing tumor tissue after metastases. It's not good or bad. Debulking just removes tumor tissue. The goal is slowing progression.

[Shorehousejam in reply to Tall_Allen]

My apologies the above pathology states it was removed, so my understanding is debunking doesn’t apply here….

So the only cancer is at base and bladder neck, so that means on the prostate fascia is prostate cancer?

SBRT is good for that?

[Tall_Allen in reply to Shorehousejam]

Your profile states "Stage 4 Gleason 8 3 Lytic Lesions (unusual or rare)" - is that incorrect?

[Shorehousejam in reply to Tall_Allen]

yes as Stage 4 clinical stage, pathology stage p3TA

So it’s confusing to us as lay people

We assume my husband has to have radiation to prostate area/ base/ fascia and bladder prostate neck. Is that even possible?

and found this on p3TA

journals.lww.com/ajsp/Abstr...

[Tall_Allen in reply to Shorehousejam]

"Lytic" means there were bone metastases. It is stage M1b (metastatic to bone). The prostate pathology is irrelevant.

[Shorehousejam in reply to Tall_Allen]

they were all resolved in last report bone, cat and pet scan

they turned back into the bone according the Medical Oncologist

[Tall_Allen in reply to Shorehousejam]

One is not restaged from M1b. The cancer is metastatic and will always be metastatic, I'm sorry to say.

[Shorehousejam in reply to Tall_Allen]

No wonder we are confused, MO stated resolved, turned back into bone…as report also has this words decrease in avidity

[Tall_Allen in reply to Shorehousejam]

The metastases shrink with chemo and hormone therapy, but once he is metastatic, he is always metastatic. That doesn't end just because the visible metastases have shrunk. The prostatectomy was for debulking purposes only.

[MateoBeach in reply to Shorehousejam]

That is indeed the right question to ask: Given positive margins and extra prostatic extension with bladder neck invasion, could salvage radiation (SRT) be potentially curative at this stage? Should consult an excellent RO. Cannot use post op PSA to guide you at this time due to the Firmagon and abiraterone. BTW why was triplet therapy employed at the start? Is there some other evidence for metastasis beyond the pelvis? MB

[MateoBeach in reply to MateoBeach]

Oh, I see below that there are lyric bone lesions making it metastatic to bone. So aggressive SRT to prostate bed would not be beneficial unless, perhaps, those oligometastatic bone sites were also treated with SBRT. But understand there is high chance for more being present but too small to be seen. Still would consult the RO about the possible choices.

[Shorehousejam in reply to MateoBeach]

Thank you