Went in T2a, came out T3a — anyone else blindsided by post-op path?

Your story mirrors mine EXACTLY. I was a biopsied as a "barely" Gleason 3+4=7 with just 6-10% of cells being rated "4". I was nearly a 3+3=6: Three cores normal/healthy/no-pathology; 3 cores 3+3=6, and six cores 3+4=7 with just that 6-10% having level "4" cells. The only other thing identified from the biopsy was perineurial invasion, which my urologist said: "don't worry, anyone with prostate cancer has it." Then came my post-surgical pathology report:
Extraprostatic Extension (EPE); Surgical Margins; Left Seminal Vesicle invasion without tumor or nodule (just cells); and Cribriform Glands. The left Seminal Vesicle invasion took me from what my urologist thought would be a T1 or T2 at worst, to a pT3b with a near-guaranteed Biochemical Recurrence and return of the cancer "within" 5 years post-op. My urologist was quietly humbled saying: "I guess your cancer was more aggressive than I thought." But he added that this was the perfect example of why he never does Active Surveillance. As he told me in the biopsy report summary appointment that discussed my options: "You have cancer, it is not going away, so why give it two years to grow and get worse?" This is why I came to name the Gleason Score "just the tip of the iceberg." You can have a disarming, low or low-intermediate Gleason Score that gets you falsely and overly confident. But you did not see the massive part of the "iceberg" of cancerous pathology lurking under water. I learned that the absolute, pivotal feature of prostate cancer that will change the course of treatment, and your entire journey, is whether you have EPE. If you have that, chances are you also had Surgical margins, and all bets are off as to how, when, and where your cancer will spread post-op, if you are one of the unlucky 25-50% of pT3b patients whose cancer comes back. My urologist said that in his practice, he averages about a 33% recurrence rate of pT3b patients "within 5 years." I hate this saying, but: "it is what it is." We've been dealt a hand and we have to play it to the best our ability and a whole lot of prayer and good luck, that we can only hope goes our way to the positive. Good luck on your journey, and keep us posted on your progress.

Yes, I had a very similar experience. 67 years old, similar health and activity levels. The cribiform to me seems to be the most important variable that was new news. Zero lymph nodes and slight seminal invasion. But, yes, this flipped the switch on me from perhaps long term maintenance to immediate treatment.

In summary, I would recommend this site and honest discussions with medical professionals. After a summer of watching my PSA slowly rise back up to .2 I entered treatment with Orgovyx and Nubequa. I also got a second opinion from Mayo Jax that helped me settle into my new reality while accepting the fact that ultimately I control my treatment plan. They concurred with all my local Tampa area treatment doctors so it has been full speed ahead. After a year I finally have settled into the reality of lifelong treatment and behavioral diet and fanatical gym/exercise change. My diet was good, now it’s absolute to the Mediterranean diet prescribed in cancer books. Books and websites are good, especially Mayo and this site. Thank goodness in today’s world of medicine there is much reason for optimism and a long life. Much longer than similar diagnosis 10-20 years ago. God bless.

I read somewhere that post op pathology seems to always find more shit. Cribiform, EPE, SVI. This is the power of full examination vs. sampling via biopsy.

In a very recent PCRI podcast, Dr. Scholtz said men with cribiform do better with radiation rather than RALP. Men with cribiform should view this video.

I didn't have the big change from pre to post op, but my situation is VERY similar: Going in I knew I had Gleason 7 (4+3), clean PSMA PET scan, .89 Decipher score (aggressive), Cribriform, IDC, possible EPE, and nerve involvement. Post surgery (9/22/25) confirmed these (non-focal EPE), plus clean margins, lymph nodes and seminal vesicles, resulting in a pT3a. I have mentally prepared for BCR in the next few years. Lrpostrp, your stats for BCR ("if you are one of the unlucky 25-50% of pT3b patients whose cancer comes back. My urologist said that in his practice, he averages about a 33% recurrence rate of pT3b patients "within 5 years.") are way more encouraging than I had in my head. Can you cite some source for those (other than just your urologist offering his opinion)? It would be really great for me and others similarly situated to feel like these numbers are well sourced and would certainly give me more hope for my situation. As always, thanks to everyone who contribute--you all are a great source of information and inspiration.

@rlpostrp Gosh...I don't understand how biopsies can sometimes be so far from reality. Almost implausible to be that inaccurate.

I was not aware of these types of situations prior to reading the posts in this thread.

To @kenkl1962
There are two reasons why the biopsy is a "12-core" sample process and in comparison to what happens to your prostate in the pathology lab after it is removed:
1) Although using an ultrasound-guided wand/probe, the urologist is collecting biopsy samples kind of blind. Through the DRE and perhaps a pre-biopsy MRI (if that happened) the urologist has a good idea where to biopsy, but they are also making sure they get all four main quadrants of the prostate: anterior, posterior, superior, and inferior in layman's terms. They likely needle-sample two maybe three cores from the same general area that they know is most likely cancerous.
2) While the needle looks long, the prostate is only the size of a walnut ("give or take"...age dependent getting bigger the older we get). The narrow-bore needle doesn't capture a lot of tissue...enough to expel into the jar of formalin preservative, but it is nothing like happens when the pathologist and histotech slice and dice your entire prostate after it has been removed. And...
The Biopsy is a "cytological" procedure. The tissue expelled into and from each sample jar is removed and put in an odd looking plastic contraption with a little funnel and a microscope slide inserted vertically. That is placed in a cytocentrifuge which spins the liquid with cells at a super-high rpm to deposit the cells on the microscope slide. Then the microscope slide is "fixed" and stained, after which the pathologist (usually) examines each slide...all twelve. They do one "pass"...a complete scanning of the entire slide, looking at the predominate type of cancer cells. This is the first number in your Gleason Score, say a "3." Then the pathologist re-scans the same slide looking for the second most-predominant cell type, say a "4". So, you end up with a 3+4=7 Gleason Score. Because some of your core samples will likely be negative/normal tissue (hopefully), your biopsy report will be a mix of what mine was for example: 3 cores normal/negative (no cancer); 3 cores that were Gleason 3+3=6; and 6 cores that were Gleason 3+4=7. Now...
3. Your surgically-removed entire prostate gland is sent to the the pathology lab, where the experienced eyes and skills of a licensed Histotech (in larger hospitals), or the pathologist themselves visually examines the cancerous prostate, and they dissect and remove areas that look most diseased. This is a "histologic/anatomical pathology" procedure. These small chunks of prostate tissue are put in paraffin blocks: hot liquid paraffin is poured over them in little tray like gizmos to give a block shape to them. Then...those blocks are placed on a microtome: think "meat cutter" in a sandwich shop that slices your turkey or roast beef into thin slices, but...the microtome slices in ultra-thin sections of the tissue, and they come off the microtome like a ribbon...all sequentially connected. Then the thinly sliced prostate tissue still surrounded by an ultra thin amount of paraffin, are put in a countertop hot water bath, where the paraffin sections are floated onto microscope slides and the paraffin melts away. There are a few little things that happen in and around each step, but those are the basics. So, ultimately, small, ultra-thin "sheets" of prostate tissue are mounted and fixed to "MANY" microscope slides. The slides are stained, and they are examined by the pathologist who can now see the much broader view of the entire prostate tissue and disease process, vs the smaller collection of cells seen in the biopsy.
The biopsy is sufficient to basically say: "You have cancer" or "You don't have cancer", and if you do, the Gleason Score reflects the maturity and progression of the cancer cells. But...they are just cells..."many" cells...but not "sheets of tissue" like happens to your post-Prostatectomy sample. The sheets of prostate tissue allow visualization of what may be EPE, surgical margins, cribriform glands, seminal vesicle invasion, Intraductal carcinoma, etc. And...
All of this, especially on biopsies, is why "so much" pathology and micro-anatomical features of your cancer are not revealed, and why we are all surprised when the post-prostatectomy pathology report comes out with all of the unexpected stuff, again, EPE, surgical margins, cribriform glands, seminal vesicle invasion, Intraductal carcinoma, etc
I hope this helps. It is pretty interesting stuff.

They have an imaging problem in the PCa business. They cant see anything until its 3-5mm dia. They can shoot things much smaller.
Also, they continue to sell RPs even though many times radiation is more effective.
Don’t want to put the uro/surgeons out of biz. And the bought all those robotic machines.
Also in other cancers the oncologists have taken the lead. But not in PCa. The uro/surgeons are normally the lead guy on your case.
In the beginning.. say 100 years ago there were only surgeons. But now there are oncologists. In PCa the surgeons don’t want to give up control.

Look up fish oil and b vitamins.
Think i read they stimulate PCa

Green tea pills
Pmagranate
Curcumin
D3/k2

Look up chris woolams canceractive

As for pathology grade matching needle biopsy grade —> Though results vary slightly from study to study, studies between 2008 - 2023 indicate that initial grade and pathological grade match much of the time.

For example, this 2019 paper out of the UK indicated that (of 17,598 patient data reviewed) initial biopsy and pathological grade matched ~59% of the time, while upgrades occurred ~25% of the time and downgrades occurred ~16% of the time: https://bmcurol.biomedcentral.com/articles/10.1186/s12894-019-0526-9

In that study, 75% of the time the Grades matched or decreased.

Yours would align with the 25% of the time when the Grade increases. Yes, it happens.