Pathology interpretation help!

@wheel1 not sure.

@ezupcic
Obviously it is a little late to think about changing surgeons mid stream with a well respected surgeon at a well respected medical institution, but it never hurts to ask. He might be on the cusp of doing it and maybe with you asking, your the one.

All the cores except 2 are positive. Even if you only have two 3+4 cores with relatively little pattern 4, the extent of the 3+3 cores means you should probably get treatment.
The good news is that is does not look very aggressive. You should get that confirmed with a Decipher test.
You should have plenty of treatment options and would likely be a goid candidate for some RT only to the prostate and without ADT. You could also look into whole gland Tulsa.

Yes I love the same drinks too. I ha read several stories where post surgery people have stopped pretty much any consumption of coffee, alcohol and bubbly drinks due to how they irritate the bladder causing more leakage. I am good to trade off alcohol as it is not healthy for us anyway ( won’t be easy though to stop). In the end, I want to do all I can to minimize or resolve post treatment impacts. Regarding ADT - I was pleased when my RO said he did not feel as though I needed it with the ADT. When I asked if it had any chance to help ensure the cancer does not grow or spread, he said, if you want some I am happy to prescribe some to you. Also, when I asked if I got recurrence down the road after SBRT, he said his plan was to give me Brachytherapy with ADT… The younger one is, the more they suggest surgery, and the older (past 70) then they push radiation. These are general statements since it really depends on pathology, if contained with in the prostate shell without EPE. And margins - even if the cancer is contained but close to the prostate shell or “ink” as they call it, then the margins are more positive. My surgeon says he thinks he may have to considered some positive margins in my bilateral case.

@ezupcic
Don’t know if your surgeon has the ability to have the tissue immediately inked by pathology during surgery so if there was positive margin he could continue getting more margin cut. That happened with me while in Surgery and my final pathology margin was negative. This is a reason for real time pathology as they only get the one shot and mine would have been positive if not for that.

@johnnyz If decipher comes back high in my case and I choose surgery with indeterminate EPE, I might be facing a future with radiation and ADT and potentially major nerve sparing problems, ED and positive margins. But with radiation and a high decipher I would be facing ADT now but my indeterminate EPE might be addressed better without impacting nerve bundles. A lot of calculus!

@wheel1 Hello, can you tell me more about the “ink” pathology in real time? Are you saying that when the surgeon goes in, they seek to know the margin they should take depending on how close the cancer is to the ink? How is the ink test/check done during the operation? I am thinking that they carefully push aside the nerves, remove the prostate and pathology is immediate on the prostate removed to determine the proximity to the ink? Does this seem an accurate assumption on the process? I am hoping that my surgeon goes in, finds out that the cancer is far enough from the ink that he can perform a negative margin or at least minimal positive margin. Thoughts?

@johnnyz
It is officially called Intraoperative frozen section (IFS) analysis. When I refer to real time pathology, you are still under anesthesia while the surgeon is waiting maybe 20 minutes to have what he cut evaluated by pathology for prostate positive or negative surgical margins through the pathology inking of the specimen. Most surgeons do not do this, they cut a pre defined margin already in their review of your MRI, PET, where lesions located, no evidence it has left capsule,etc and close you up. Unfortunately many patients will hear for the first time afterwards at the post surgery appointment they had positive margins left. Certainly sometimes this will be unavoidable due to spread, but many patients have already been advised that their appears no evidence that the cancer has breeched the capsule and the surgeon does standard margin cuts. In my case , my surgeon was surprised as he believed I had no cancer out of the capsule , did his standard cuts, and even from his observation having done over a thousand surgeries saw nothing in the surrounding tissue that appeared out of the ordinary. When it came back positive margin, he had to go in delicately to get more and my surgery extended over two and 1/2 hours entirely messing up his surgical schedule that day with his afternoon. I don’t know how much if any extra money he gets for that, but I think most surgeons want to open and close and not hang around for that or substantially additional surgery time. I was notified at my post surgery that I had negative margin.

This clearly is only done at major hospitals that still have their pathology departments in house. I know many times tissue is now sent to off site pathology that review for alot of others also.
This is becoming more common as the Retzius Sparing has also.

@johnnyz
It is officially called Intraoperative frozen section (IFS) analysis. When I refer to real time pathology, you are still under anesthesia while the surgeon is waiting maybe 20 minutes to have what he cut evaluated by pathology for prostate positive or negative surgical margins through the pathology inking of the specimen. Most surgeons do not do this, they cut a pre defined margin already in their review of your MRI, PET, where lesions located, no evidence it has left capsule,etc and close you up. Unfortunately many patients will hear for the first time afterwards at the post surgery appointment they had positive margins left. Certainly sometimes this will be unavoidable due to spread, but many patients have already been advised that their appears no evidence that the cancer has breeched the capsule and the surgeon does standard margin cuts. In my case , my surgeon was surprised as he believed I had no cancer out of the capsule , did his standard cuts, and even from his observation having done over a thousand surgeries saw nothing in the surrounding tissue that appeared out of the ordinary. When it came back positive margin, he had to go in delicately to get more and my surgery extended over two and 1/2 hours entirely messing up his surgical schedule that day with his afternoon. I don’t know how much if any extra money he gets for that, but I think most surgeons want to open and close and not hang around for that or substantially additional surgery time. I was notified at my post surgery that I had negative margin.

This clearly is only done at major hospitals that still have their pathology departments in house. I know many times tissue is now sent to off site pathology that review for alot of others also.
This is becoming more common as the Retzius Sparing has also.

@johnnyz I also have bilateral disease and tumors near the capsule border but indeterminate EPE. With positive margins potentially does that mean they would start radiation and possibly ADT post surgery?