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.

@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.

@rlpostrp

Sorry, but your description of needle biopsy slide preparation is 100 % WRONG
.
It is done with this method :

"Prostate needle biopsy slides are prepared by fixing tissue cores in formalin, embedding them in paraffin wax, and slicing them into 4–5
m sections using a microtome. These thin sections are mounted on glass slides, stained (usually with hematoxylin and eosin), and examined microscopically by a pathologist to detect cancer".

So, it is NOT centrifuged by any means. The WHOLE sections are placed on a microscope slide and examined as a tissue , not "whatever sticks on a slide" after centrifuge.

Since the whole long section is examined (12 or more of them), pathologist can see not only the type of cells but how they are arranged and what gleason dominates and in what %.

If needle passes by EPE and catches it - it will be seen on a slide. When it passes neural pathways it will catch that part and pathologist will see if cancer is present around nerve ends. If it catches tissue that has IDC present, than ducts with infiltrated cancer cells will be seen.

So needle biopsy is not sometimes wrong because it can not see things, but because needle biopsy examines only about 1 % of the WHOLE gland so if it misses on its path the worst lesion, the result will not be 100 % correct.

@surftohealth88 Thanks for your input. You are not entirely correct or incorrect. Some pathologists want their small volume biopsy core samples processed that way using paraffin blocks. The analogy offered here explains the inefficiency, and the need for a very patient histotech/cytotech and pathologist. The paraffin blocks from the cassette tray gismos are about 20mm (3/4") square. Imagine placing a few bread crumbs in the 3/4" x 3/4" paraffin block vs a small piece of bread. They can find the small amount of bread crumbs...but it takes longer, but it doesn't take too much more time, but it is a waste of all of the paraffin and minimal space occupied by the small sample volume in the block. So...
I encourage you to type into your browser search bar: "Is a cytocentrifuge used in processing prostate needle biopsy tissue for microscopic examination?" I did...Here is the "copy/paste" answer with focus on the key words like "concentration" and "monolayer":
"Yes, a cytocentrifuge is used to prepare prostate cells for microscopy. This technique allows for the 'concentration' of cells onto a microscope slide, creating a 'monolayer' that facilitates examination. The cytocentrifuge uses centrifugal force to deposit cells from a fluid sample onto the slide, which is particularly useful for analyzing prostate specimens in clinical settings.
How it Works:
A funnel assembly is attached to the slide, lined with filter paper to absorb excess fluid.
A small volume of the sample is placed in the funnel, and the centrifuge spins, depositing the cells onto the slide in a concentrated manner."

While some (a lot?) of pathologists might use the paraffin block method on the very small sample size from the needle biopsy, "all" of the Labs in which I was a Director for my career, used the cytocentrifugation method. Use of paraffin tissue blocks was reserved for actual "pieces" of post-surgical tissue. The procedure you describe is what happens more often to the tissue once the prostate is removed, and - per my first comment - sees the pathologist or histotech - visually examine ("gross") the prostate and dissect/sample the most suspicious/diseased parts of the prostate, then...as I mentioned as "a few other steps in between," the tissue is processed over night, then is placed in the cassette trays ("gismos") for the hot paraffin wax...the the blocks with the chunk of tissue are section in micro-thin sections on the microtome. Those sections are mounted on slides with he paraffin being melted away. The slides are then stained and examined.
Unfortunately, the term "biopsy" and post-prostatectomy tissue processing have been blurred. There have been a lot of guys on this blog who talk about the "biopsy" of their prostate "after" it has been removed. That is technically incorrect use of the term "biopsy." "Biopsies" occur before surgical removal from the body. The more correct term for the post-prostatectomy handling of the prostate would be: "gross histopathological handling and processing of the prostate, and examination of microtome-sectioned, stained tissue on microscope slides by a pathologist." So...
You're right...some people do it the way you searched and found, but most don't in my experience in California hospital-based Clinical and Anatomical Laboratory services. I appreciate your passion.
Thanks for the commentary.

@rlpostrp

My husband's needle biopsy was done using method I described and every study I read used that method, but perhaps some "drive through" labs use centrifuge. All photos in studies were clearly ones of long tissue samples being examined and digitally photographed and saved. Like this one:

@surftohealth88 Nice photos...not sure what you mean referencing "drive through" labs unless you were being pejorative. There is of course no such thing as a "drive through" lab.
"Long tissue samples" is a relative term. One of the first things a urologist will note is the "length" of the core sample when expelled into the jar of formalin. Per the literature on the subject, the typical core is about 11.3 mm (0.44") long because the prostate is only the size of a walnut: 4cm x 3cm x 2cm (1.6" x 1.2" x 0.75"), therefore, a 0.44" core has traveled through almost half of the prostate. And...(interestingly)...
Per the literature, core biopsy "length" is actually an initial quality assurance reflection of the probability of cancer being present or not. While the size of the cancerous prostate is often bigger (tumor occupies more space in the slightly enlarged prostate), prostate size is not a definitive, diagnostic criteria for cancer. Size is however, a reflection of patient age though, as the older a man gets, the larger his prostate is. But...apparently, it is generally accepted within the world of urologists and pathologists, that a core length size of >11.9 mm (greater than 0.47") is highly suggestive of cancer. Anything less is not definitive, and cancer cannot be completely ruled out, but is apparently less a likely probability than the slightly longer cores.
Interesting stuff. The "passion" on the subject offered by "@surftohealth88" in this post, got my curiosity up to look into core length. I knew (had a very good hunch), that the length of the cores could not be very long, just based on the small size of the prostate itself. I initially guessed 1/2" - 3/4". I learn something everyday.