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Surprising Gleason Score

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Posted 6/3/2015 1:08 AM (GMT 0)
Thought I'd post my experience for those wondering when to seek treatment given lower Gleason score. My last biopsy (Feb 2014) showed 3+3 = 6. At that time I was advised to consider treatment but wasn't being pushed to do it immediately. In addition, URO wanted me to lose some weight as I had decided RALP would be treatment of choice. RALP 5/18/15. Pathology stats below but Gleason went to 4+5=9. Margins were clean thank God but doctor said he was surprised by the Gleason score and that he didn't see that change very often. Post surgery, the worst part for me was the uncomfortable bloating and catheter irritation (8 days). Incision pain was fairly low.
Posted 6/3/2015 1:42 AM (GMT 0)
Welcome to the forum, but sorry that you need to be here. You've found a very supportive place!

That must have been a shock to have such an upgrade in Gleason. That doesn't happen often, but it does happen. One of our leading forum contributors, Peter DisAbleard had quite an upgrade after RP.

The good news is clean margins. The less good news is that G9s are kind of unpredictable, and subsequent treatments are more likely that they would have been with a G6 or even G7. Being only 5% is a plus, the PNI hasn't shown itself to be a big risk factor generally.

Some of the more knowledgeable members will be along shortly I'm sure.

We have a thread for the Gleason 9 folks, so you can get in touch with others in similar situations. Here's a link to it, and in it is another link to a longer earlier one. Lots of info and other G9 folks in those, so you may find some help there too. Here's the link:
www.healingwell.com/community/default.aspx?f=35&m=3182035&g=3182504#m3182504

Stay with us, we're all here to help each other!
Jerry
Posted 6/3/2015 1:50 AM (GMT 0)
Redwing57,

I appreciate the comforting insight and seeing your positive PSA results. My next PSA is in three weeks (or 6 weeks post op). Hoping to see some reduction at least but seems from other threads that may be a bit too soon for significant change. I've lurked some in the G9 thread but will be spending more time there in the coming days.
Posted 6/3/2015 1:55 AM (GMT 0)
Hi!
Welcome to HW forum..
Sharing the route of my treatment...I m oso a G9
All the best to your coming PSA test result.
Posted 6/3/2015 3:58 AM (GMT 0)
While the needle biopsies can show G-6 and provide some comfort, 30% of the time, when surgery is performed, the complete pathology reveals a higher Gleason score. This is what makes AS somewhat more risky than it seems on the surface...You can never be SURE it's all low-risk G-6 malignancy..
Posted 6/3/2015 4:55 AM (GMT 0)
Welcome to HW.

Good to hear you're on this side of surgery. Keep us updated. It's not uncommon for there to be an upgrade in the post op Gleason score.

yes, six weeks is a bit soon for a PSA, but it should be lower. At three months you'll have a better test.

Hang in there,
Andrew
Posted 6/3/2015 5:51 AM (GMT 0)
Welcome to the forum. You seem to be a positive and optimistic fellow. So are the folks here and that is a real plus with a high Gleason. Keep educating yourself. There are a lot of treatment options out there that will help you live a long and happy life.
Beth n Gary
Posted 6/3/2015 9:26 AM (GMT 0)
Greetings and welcome, Newgrange

That upgrade from a G6 to G9 is scary! We had a discussion before whether a G6 could morph into a 7, 8 or 9? The answers were not definitive!

My question is, when you were diagnosed with a G6, did you have a second opinion from a lab that had experience with Prostate Cancer specimens?
.
Posted 6/3/2015 12:00 PM (GMT 0)
No, I did not get a second opinion on the G6. Wasn't aware of the advisability of that at the time of the biopsies unfortunately. And don't know which lab my URO used for that but would have to assume they get a lot of specimens from my URO so would have had some experience. I'm encouraged by your low post-op PSA's.
Posted 6/3/2015 12:51 PM (GMT 0)
New grange, welcome to the forum.
It's not at all unusual to be upgraded on surgical pathology, as you've already been told. It is, however, not that common for a G6 to go to a G9. I'm guessing that even if you had gotten that second opinion on your biopsy slides, it wouldn't have come back as a G9, the G9 was probably from a different part of the prostate, that was completely missed by the biopsy needle. While grading of prostate cancer cells is subjective, G9s look very different from g6s,

With that said, just thinking out loud, I wonder if it would make sense for you to get a second opinion on your surgical pathology. Someone more knowledgeable than me will hopefully chime in with some educated comments (Tall Allen?)

The good news, is that at least now you know what you are dealing with and can approach it with the best strategy. Even G9s are highly treatable, and with your pathology X the Gleason score, you might even be done with this, as is "we got it all, you're cured"
Posted 6/3/2015 1:06 PM (GMT 0)

Newgrange said...
Thought I'd post my experience for those wondering when to seek treatment given lower Gleason score. My last biopsy (Feb 2014) showed 3+3 = 6. At that time I was advised to consider treatment but wasn't being pushed to do it immediately. In addition, URO wanted me to lose some weight as I had decided RALP would be treatment of choice. RALP 5/18/15. Pathology stats below but Gleason went to 4+5=9. Margins were clean thank God but doctor said he was surprised by the Gleason score and that he didn't see that change very often. Post surgery, the worst part for me was the uncomfortable bloating and catheter irritation (8 days). Incision pain was fairly low.

WOW! What a kick in the groin! But it just goes to show it's all a crap shoot with these Bxs because they can easily miss something. That does not mean having a G6 means you are at all more likely to have a G9 or turn into a G9, but it is always possible that something else is in there. And the only way- so far- to ever really know is to cut the rascal out and have a look at it, kind of an extreme means of Dx!

It really is no different for anyone who has not even had a Bx. Any man who has not had a Bx could have a G10 in there for all he knows. In fact, a lot of men over 60 and most over 70 or 80 have some PC cooking away in there, and autopsies(done in counties where PSA testing is not common) show that a significant # of those men with undiagnosed PC also have pretty aggressive cancers. But they died apparently never even knowing they had PC, much less an aggressive Gleason score.

So we can be pretty sure that whatever Bx shows, that is actually in there although those also get downgraded. But whether we have had a Bx or not, we are never sure there is not a much higher G score in there unless the Bx starts us out with a 10. At the moment, you have to cut it out to know for sure. Sorry for your bad luck on the massive upgrade, but glad to hear it was contained! I wish you an unusually good recovery from surgery in all ways!
Bill in MS
Posted 6/3/2015 4:12 PM (GMT 0)
I had a similar upgrade, as some others have mentioned. I only had one positive core and my initial biopsy report had it at 3-4 percent Gleason 6(3+3). I had a second opinion on the biopsy samples. I had "recuts" where they take a different slice off of the same cores so the second opinion sees slides from different spots in the sample. The second opinion agreed with the 3-4 percent involvement and with the limit to a single core but it bumped my Gleason to 7(3+4). Then after my RP the pathology report came back with Gleason 9(4+5) and some smallish positive margins. So, yes, I know what a delightful surprise such things can be.

Welcome to the forum.
Posted 6/3/2015 5:46 PM (GMT 0)
I'm shocked too! A recent study showed how unusual it is for men on AS to have their Gleason score go up that much. Biopsies are just random samples of the most likely places that tumors appear, but sometimes they grow in less likely places that are undersampled (like the anterior zone). This is why many uros now advocate mpMRI-targeting on f/u biopsies. Did the path report say exactly where the GS 4+5 was found.

The good news is that your margins were clean and you were staged T2. So all you can do is watch PSA closely and be prepared to act with ADT+ early salvage radiation if PSA doesn't reach or stay undetectable. A nerve-wracking experience!

Prat- Because pathologists get to see whole tumors after RP, it isn't subject to the same kinds of errors caused by partial sampling and core angle artifacts that biopsies are subject to. I guess a rookie pathologist can get it wrong, but I'd imagine it was reviewed by a senior person. There may be a photo in the path report.

- Allen
Posted 6/3/2015 11:32 PM (GMT 0)
Allen, i understand that. But i always thought that looking at the cells themselves and calling them a specific grade is a very subjective process, i.e. two pathologists looking at the same cells can call them two different G scores. Maybe i misunderstand.

My pathologist (i looked her up) was a long tenured pathologist with many years of experience, whose profile said she specialized in genutoury cancers. And yet her premise was disputed by Epstein. Strange.
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