Pathology was just a difficult case. There was definitely viable tumor adjacent to bundles of smooth muscle, but probably different pathologists made different interpretations of the muscle. Since smooth muscle can be found in some areas in the lamina propria and makes up the walls of arteries, the decision is based upon the quantity and quality of the smooth muscle. I, too, had a 2nd turbt, but in this specimen there was definitely no muscle wall invasion and there was substantial smooth muscle to evaluate. Yet one month later at rc there was a very small area of invasion into the very superficial aspect of the muscle wall. Given the two events after the initial turbt, I have no idea whether the folks who thought the initial was muscle invasive were correct or if this occurred in the interim. My personal feeling is that the initial turbt was best interpreted as indeterminate but highly suggestive of muscle invasion which was one of the interpretations. I do not believe there was sufficient evidence to deem it muscle invasive, but too much uncertainty to say no invasion. It's just a fluke that I even sought another pathology opinion (other than the ones that are routinely done as a part of a 2nd clinical opinion). I asked one of my partners what he thought about a particular area in terms of CIS and his response was he did not think what I asked about was CIS, but did think it might be muscle invasive. When he showed me what he was talking about, I did not think I could be absolutely sure either way and sent it to Hopkins. Reasons for differences in pathology interpretation are many, but usually occur in difficult cases in terms of interpretation. Then you deal with consulting pathologists who most likely look at the exact same thing and arrive at different conclusions, some are often much more aggressive in what they require in order to call something ca or in this case muscle invasive and others are much less so. It is a difficult line to walk, because, as a pathologist, you want the patient to have the most appropriate treatment without being over treated. In the case of muscle invasion vs not in the urinary bladder, this is a dramatic difference - huge surgery vs conservative treatment. This is one good reason to get a second opinion from someplace that does a lot of bladder ca, since it comes with a pathology opinion from a department that sees a lot of bladder ca. I bet that 95% of the time there is complete agreement, but if you are in that other 5% you then face who to believe and what to act on. For myself, I thought I would not be able to live without significantly second guessing myself, if I didn't act as if it was the worst possible and give myself the best chance for a cure from that worst possible scenario. Hope this helps to explain the dilemma a bit better.
jj
