SM writes:

> The note on the 3/21/97 biopsy said: Immunohistochemistry pending.

> · In mid July, after I sent the digest, and just before we went away, I

asked

> Dr. Block about the small cell features, and he said that indeed he

checked

> with the lab and that there was no small cell. In your opinion, do you

think

> that the slides need to be re-read by another pathologist?

If the lines of communication have stood up to the game of "telephone" then

there is no reason to have the slides reviewed. Small cell carcinoma is an

"exciting" find for the pathologist, even though it means a poorer than

usual prognosis for the patient. If the pathologist thought it was small

cell, it would certainly get on the report (especially if the urologist

asked him specifically to check for this).

So if there is a silver lining to the very dark cloud that has fouled-up

your life recently, it may be that your husband does not have small cell

cancer.

>

> >From every reaction I received, this is just about the most aggressive

cancer

> anyone has ever seen and not your average, run of the mill prostate

cancer.

> OK, so let's say that this is small cell carcinoma and scc is rare.

> However, it's not rare in our household. Here 100% of the adult male

> population have scc.

According to the pathologist, your husband does NOT have small cell cancer.

He has a bad case of metastatic poorly differentiated acinar-type (meaning

usual-type) prostate cancer. This is a better alternative if one must

choose between one or the other. It is a tragedy that you were not given

the opportunity to choose neither of the above.

>

> Does anyone know or can point me in the direction of anyone who has

studied

> scc?

I have diagnosed about a dozen cases, and I have a decent sized file on SCC

journal articles; it represents a large distraction to us if the disease is

not SCC.

> I pointed out to Dr. Block that after the first LHRH treatment, with

Zoladex,

> Mike had sweats - hot and cold, and the PSA # was going down.

AHA! Here is the circumstantial evidence I was looking for. SCC typically

does not respond to hormonal treatment. Thus it is even less likely that we

are dealing with it. I could review the slides if you'd like; personaly I

think you'd be better served by a dinner with your husband at a fine

restaurant (serving low-fat foods of course).

I trust the oncologists on-board will answer your therapy-related

questions.

Best wishes,

JR Oppenheimer

Prostate Pathologist

********************************************

Dear Siora and other interested parties,

Here's the scoop from a review of my files and the two pathology

mini-bibles on the subject.:

Approximately 10% of prostatic adenocarcinomas contain cells which produce

neuroendocrine (NE) substances like NSE and CGA. Neuroendocrine

differentiation seems to indicate a poor prognosis when it is present since

these cells may not be responsive to hormonal therapy. According to

Bostwick's 1997 _Biopsy Pathologyof the Prostate_, the cells showing large

eosinophilic granules (indicative of NE differentiation) also stain for PSA

and PAP. Some poorly differentiated tumors with NE differentiation have the

appearance of so-called carcinoid tumors. According to Epstein's 1995

_Prostate Biopsy Interpretation_ these tumors stain for PSA and PAP (in

addition to the NE markers) and clinically behave like ordinary

adenocarcinomas. Bostwick prefers to put the carcinoid pattern in a

category of low-grade SCC.

Small cell carcinomas (SCC) look like the more common SCC's of the lung.

According to Epstein, they may be positive for NSE and negative for PSA and

PAP, negative for NSE and positive for PSA and PAP, or negative for all

three antigens. According to Bostwick, these cells may express PSA and PAP

in addition to the NE markers, but pure SCC does not usually display

immunoreactivity for PSA. According to Abbas' and Soloway's review of SCC

(Urology 46:617, 1995), if the tumor shows diffuse positivity for PSA, it

most likely represents poorly differentiated PCa rather than SCC.

So to summarize, if the cells show strong PSA or PAP reactivity and only

scattered or focal CGA or NSE reactivity, its more compatible with PCa with

endocrine differentiation. If the NE markers are stronger than the prostate

markers, a SCC is likely. There is an art to interpretting the

immunoperoxidase stains. It MUST be done in conjuction with evaluation of

the cellular architecture (how the cells look and interact with their

neighbors) of the tumor. Paraneoplastic syndromes (symptoms produced by

excess production of non-androgen hormones are more consistent with SCC.

I admit this is a little confusing. The way it looks under the scope is

key.

Best wishes,

JR Oppenheimer,

Prostate Pathologist