After RP who goes over Pathology?

[Shorehousejam]

We messaged Surgeon through portal and asked how many lymph nodes removed. He states that pathology will tell us that…Does the medical oncologist go over the surgery pathology?.

My husband has great physicians, but definitely confused by these mixed messages of whom is willing to give my husband answers.

It’s always very difficult to get a straight answer.

At the bottom of this report there is verbiage, are those lymph nodes removed.?

GBG OPERATING ROOMAge/Sex: 61 / M CLINICAL INFORMATION:Prostate cancer (C61).

Per EPIC: Status post chemotherapy.

CANCER SYNOPSIS:PROSTATE GLANDI. PROCEDURE:

Radical prostatectomyII.

HISTOLOGIC TYPE: Acinar adenocarcinomaIII.

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 neckpN0: No regional lymph node metastasisV.

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 neckVII.

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

SEMINAL VESICLE INVASION: Cannot be assessedIX.

EXTRAPROSTATIC EXTENSION: Present, nonfocalX.

URINARY BLADDER NECK INVASION: PresentXI.

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 the 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.

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. (

[cesanon]

I have observed that being able to get an understandable answer to a question is an indicator that you have a competent Doc.

Einstein quote: “If you can't explain it simply, you don't understand it well enough.”

Time to start getting some second opinions with the intent of finding a Doc that can explain what they are doing and why.

[Teacherdude72 in reply to cesanon]

100% agree! If your doctor is an Oncologist with strong experience with Prostate Cancer they can, will, explain in terms you will understand. If a urologist most can't.

[Hidden]

They took out 8. none had active cancer. 1 looked like it had cancer but whatever treatment you had before surgery seems to have eradicated it.

[Tall_Allen]

Your oncologist can explain this (not the surgeon or the pathologist). 8 lymph nodes were removed, including 1 in which the cancer had been eliminated by chemo. None of this is important in making future treatment decisions, because he is still Stage M1b.

[Shorehousejam in reply to Tall_Allen]

Tall Allen, it was suppose to be an extended lymph node removal, the surgeon did no mri before surgery but did a pet scan…once In surgery did the surgeon decide to only remove 8 lymph nodes because he saw there was no cancer in the pelvic lymph nodes during surgery ? …confused as to how in the hell it went from 16/18 lymph nodes removal down to 8… when they were no complications at all

[Tall_Allen in reply to Shorehousejam]

It really doesn’t matter. More lymph nodes means greater chance of side effects.

[Shorehousejam in reply to Tall_Allen]

if there are remaining cancerous lymph nodes, it matters…

Different cancer care of excellent hospitals like Mayo and Yale go for curative intent…where my husband goes to

They like circling the issue.

Fed up

[Tall_Allen in reply to Shorehousejam]

Sadly, when there have been bone metastases, it is incurable, but manageable. Metastases are like mushrooms, so picking every last one doesn't matter. For every one you can see, there are hundreds more that you can't see. Neither Mayo nor Yale have ever published any cures. In fact, here's what Mayo published:

nature.com/articles/s41391-...

They either removed pelvic lymph nodes/irradiated metastases or they gave no treatment other than ADT:

• The 5-year prostate cancer mortality was no different after treatment

• The 5-year radiographic recurrence-free survival was no different after treatment

[Gl448 in reply to Tall_Allen]

”it is in curable, but manageable. Metastases are like mushrooms, so picking every last one doesn't matter. For every one you can see, there are hundreds more that you can't see. ”

That is a brilliant analogy that is easy to wrap your brain around. I’m going to start using it to explain to people why I say I can’t be “cured” with current treatments.

[Shorehousejam in reply to Tall_Allen]

Right, I think that is why the swog trial is underway, to see if prostate removal and/or radiation makes a difference against just hormone triplicate therapy.

There is also a study that you may have that there is no difference of end result whether it be with 6/8 lymph nodes removed and up to 18/26

I personally think and obviously Not medical versed, removing 18 to 26 lymph nodes is just crazy.

To me it most likely would cause lymphedema, which is just awful with no QOL.

[Tall_Allen in reply to Shorehousejam]

💯 The danger of lymphocele and lymphedema precludes a high number of pelvic LN dissections. I know that Karnes at Mayo likes to get a lot of them and it is widely practiced in Europe, but I never understood why. Radiation is much less toxic (if used without surgery).

[Shorehousejam in reply to Tall_Allen]

Why risk lymphocele or lymphedema

Am I reading, absorbing that correctly …that studies or research have shown that no matter how many lymph nodes are removed …the end results are very similar?

[Tall_Allen in reply to Shorehousejam]

Yes.

[London441 in reply to Shorehousejam]

Surgery is always done with ‘curative intent’, which is great when it works. Statistically it doesn’t 30% of the time. For those for whom higher stage disease is discovered post op it’s probably closer to zero.

I was T3b and was a bit surprised I was told right away that additional treatment would be needed after my surgery. Weirdly I was filled with optimism. Perhaps this was I had a confirmed 4+3 Gleason, which I interpreted as significantly better that 4+4 or higher. I ignored the fact that 80% of the 4+3 was pattern 4 in the positive cores. I also had seminal vesicle invasion but I didn’t know the seriousness of that.

Additionally, I was relieved that only’ 1 out of 15 lymph nodes removed were positive, which I learned was akin to finding only one cockroach in your kitchen.

PET scans weren’t available at that time, but I could certainly have made a better choice than surgery based on the MRI guided biopsy, which showed a lesion with multiple cores of 4+3 butting against the edge of the capsule. Clearly I had not done my homework.

[dhccpa in reply to Tall_Allen]

Given that, one has to wonder if all manner of useless treatments are pushed onto patients when ADT would have done the trick.

[Tall_Allen in reply to dhccpa]

That's why God invented randomized clinical trials 😀

[dhccpa in reply to Tall_Allen]

Good point!

[Revcat in reply to Tall_Allen]

I’m intrigued by this comment. At UCSF, I didn’t see an oncologist until over 2 years after surgery and both RP and SRT had failed. It seems to me odd that the only docs assigned to me before then were each specialists in a single approach to treatment, leaving the patient — me — to choose between pitchmen based on somewhat dubious factors such as fame, how they treated my partner who was also in the room, etc. They both “correctly” acknowledged that the other’s approach was reasonable. That and 50 cents used to get you a cup of coffee. What I needed was a concierge with no horse in the race to help me sort it out.

Your reference to an oncologist’s interpreting the path report made me wonder. Who’s got an oncologist at that stage of the proceedings? Is my experience typical: i.e., no oncologist assigned until after the definitive treatments have failed?

[Tall_Allen in reply to Revcat]

This comment has nothing to do with the OP's situation, so apologies for hijacking his thread...

For those with localized PCa, there is no such thing as " a concierge with no horse in the race to help me sort it out." Everyone has biases. One MO, who I've met, wrote a book called "Invasion of the Prostate Snatchers" against prostatectomy. Other MOs, unfamiliar with radiation results, may poo-poo that therapy. Medical oncologists are specialists in the use of medicines to treat incurable prostate cancer. They are not trained in surgery or radiation oncology, and may know less about those therapies and their results than you or I do. In this age of specialists, asking an MO to advise you about localized PCa is like asking an electrician for advice on plumbing.

The only biases that matter is yours. Only you know what is important to you. Your doctors were quite right to tell you the risks and benefits of each therapy, and leave the decision to you. This is called "shared decision making" and is taught in med schools. Long gone are the days when doctors dictate therapy.

It's too late for you now, but this article speaks to your interest:

prostatecancer.news/2017/12...

[Revcat in reply to Tall_Allen]

More like I'm the one who should apologize for the hijacking. That said, I didn't say I wanted a doctor to dictate therapy. I've got a file drawer full of research papers that I've read during the course of my 8-year journey with PCa. Your article from 2017 contains much advice that is never too late and pretty much reflect my own approach to interacting with my doctors. That said, my question was about the likelihood of having an oncologist to interpret the pathology report. In my case, at a center of excellence, no one went over it with me, at least not to discuss the significance of the tertiary 5 that the biopsy missed. Perhaps your comment was specific to the OP's situation but I took it as more general. I may have read something into your post that wasn't there.

[Tall_Allen in reply to Revcat]

It used to be that path and radiology reports were discussed in person or by phone by doctors. Now, they are given to the patients early on the patient portal. If the patient isn't a medical expert, he may not know what needs to be discussed with their doctors. Things fall through the cracks. The report should be discussed in person with whatever doctor ordered it.

[maggiedrum]

Regardless of whether there will be any treatable items identified in the pathology report, your oncologist should review any and all reports since it is important information to know if you have or don't have any "issues". And then they should give you their opinion on what they interpret the report to say and its significance. And, especially if you have specific concerns and questions on any report, the MO should give you an informed answer based on the report you have identified any concern, or even if it is just educational.

Doctors should be a part of your "team" and give you some education on what is happening, and could/might be significant. Then, they can give you the info on whether it should concern you, or not, including therapy options, if any, to give you the best prognosis of a favorable outcome. My MO seemed to belong to the school of "I am a very busy doctor and all I need to tell you is what I think is important regardless of whether it is freaking me out or not due to my lack of understanding". I reminded him that this is a very special time in my life and I don't have the understanding as to how to do a review of all known papers on each situation, especially if I don't have the competence to understand what these papers have on me personally.

I educated him on what I considered to be his job and one of the reasons he was on my "team". If he had not changed I would have changed to a different oncologist. I understand these doctors are busy. They don't have to give you a tutorial on the state of cancer research and evidence of which therapies work in general. But they darn sure should give me answers to my concerns. If they think they are not important I want them to tell me.

My doc did tell me later after a PSMA-PET/CT scan what the finding of multiple lymph nodes scattered through me meant. As TA mentioned below, having multiple small cancer findings makes targeting these nodes with radiation and/or surgery would not be helpful. I was left understanding, not happily, that these finding of metastasis in all these lymph nodes make it highly likely that the cancer will spread, either in the near or long term. But now I am better educated in my options and have a better understanding on my prognosis overall.

Also, as it turned out the surgical pathology done after my RP was 100% important for my prognosis (extensive extra capsular cancer cells in all quadrants). Because of my background, although limited, I could find literature on this and the very bad prognosis it meant. But my MO definitely should have explained that to me, rather than the hospital radiologist just telling me I needed radiation, just because, and also telling me he would prescribe ADT, or have my surgeon prescribe it. My surgeon just disappeared after one consultation and subsequent MRI and bone scan. I immediately sought out 2nd opinions from another radiologist and oncologist who specialized on prostate cancer. I still have hard feelings about the original, very unhelpful, doctors.

I found that the recommendations were SOC and basically the same as the first docs but I got good explanations on all of it and even though I was not happy I at least had comfort in having a better understanding of what it all meant.

[RMontana]

You would need to confirm this with the surgeon; only he can tell you. But there were 8 that were examined and they were negative. From what I have read pathology examined 'removed' tissue...so if they reported 8 were negative they would have had to be removed...but again you surgen must tell you...

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

I had bladder neck invasion as well and had radiation before I was dry...I have permanent leakage now...I did not wait to be totally dry before getting sRT (salvage X)...if your husband is in the same boat let him know...the leakage he has going into sRT is what he will have for the duration. TNX

[TylexGP in reply to RMontana]

When I consulted with the Urologist at MSK he was very straightforward and clear that if I needed RT post surgery which was likely given my N1 disease that my incontinence would remain basically where it was at the time of RT. He also stated it might make insertion of an artificial AUS impossible.

[RMontana in reply to TylexGP]

He is right...what you have going in is what you will have coming out...I was told to proceed when I was 'less than 1 pad,' which was wrong...I chose to be more aggressive and so I am stuck with low leakage; not bad but not dry. There is also a chance that radiation of the bladder neck will affect the remaining sphincter (I had only 0.9cm) which will also develop some leakage; hope this is not your case.

Here is what I found with my research on how I could be dry again and if an AUS would work for me...summary as I understand it. xRT (salvage radiation) will not allow you or me to get a Sling; they wont work for us. Appears that the urethra is damaged by xRT and a sling wont work. Also, if the leakage is low I was surprised that an AUS (artificial sphincter may not work! Check out this study...

healthunlocked.com/active-s...

...my urologist also told me not to consider an AUS with my low leakage (10-25 ml a day)...he said that an AUS is meant to bring a man with extensive leakage to 1 pad, not to take a man at 1 pad to a dry state...this study bears him out; its not 100% dry results! Others on this site have said that their AUS made them dry...dont know. I may consider a ProAct implant...check these out! But a sling wont work for me and an AUS may not provide a dry state...but I like the ProAct as it allows you to control how much pressure to put on the urethra...

Last think Brother...dont forget your ED and the state of your penile tissue...I waited too long to act and had atrophy...the longer your wait the more loss you suffer. Keep an eye on all three aspects of our battle; Cure-Incontinence-ED...we forget about the last part and think about it when many options have left the station...good luck. Rick

[Grandpa4]

the pathology report states that 8 lymph nodes were removed and no cancer was found.