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Posted 2/9/2016 6:25 PM (GMT 0)
Hello All, Im about to start my Cyber-Knife fiducial implant next week. about 2 weeks ago when I had a visit with a HDB RO ,at Loyola medical center ,he wanted to do their own reading of my slides before they do anything .As my signature says,Quest gave me a 4+3 and John Hopkins downgraded me to a 3+4.

In the mean time I decided on SBRT at Lutheran general,with Dr.Arica Hirsch.So almost forgetting about the HDB visit,I get a call yesterday from Loyola and the RO said my slides that they read was 4+3.So I called my C-Knife Dr.and said she would stick with John Hopkins report.Tall Allen also said JH wins hand down as well as others.. So its very important for the new guys to listen to what our wise elders say,get your second opinion from JH or Bostwick.Another visit with a Cyber-Knife Dr. told me even with a 4+3 he still would do mono-therapy that it didnt make that much difference to him.But Im not too shure about that ???

Also I just picked up copies of my latest lab blood draw from my local Hospital today.My PSA has risen to 6.87 from 5.72 on Sept. 2015.I know I have PC but does that rise more than a full point in 5 months mean the cancer is on the move ? I was careful not to stir up the prostate before the blood draw,wink,wink.
Posted 2/9/2016 6:46 PM (GMT 0)
It may or may not be good advice for new guys. It is more common for JH to upgrade than downgrade and the concur with 80-90% of low grade outside evaluations. You may be rolling the dice more than you think you are.
Posted 2/9/2016 6:55 PM (GMT 0)
So wouldnt you think it would be good to know either way so we can narrow our options ?
Posted 2/9/2016 7:27 PM (GMT 0)
It would..but you don't know either way for sure no matter what JH says..at least 2 other pathologists don't agree , you clearly don't believe them...I get it...just sayin'. Anyway what would be the alternative...surgery, hormone therapy....GAK. You're on the right track it seems to me..so just stay there..like you are doing.
Posted 2/9/2016 8:37 PM (GMT 0)
No, it wouldn't make much difference if it's GS 3+4 or 4+3 for SBRT. They treat 'em both the same way, same margins, same dose, etc. In fact, the ROs who do SBRT monotherapy for high risk PC, only widen the margins a little. Epstein is bankable. That doesn't mean it wouldn't change if they took out your prostate and they were able to look at everything. It just means it's the best info based on what you now have.
Posted 2/9/2016 9:09 PM (GMT 0)
Sheepguy,Its not that i dont believe them, I do.I believe that they believe in what they saw in the slides was the best call to make with the knowledge given them.I also believe that John Hopkins and Bostwick have the prostate cancer dialed in. This cancer keeps on giving . From day I decided I wanted a 3T-mpMRI.I got it.Then everything else fell into place.I did everything I could to put the odds in my favor to help me make that one final decision,surgery or radiation For my Wife and myself I feel very confident going forward . I like rolling the dice,but only at a crap table.

Post Edited (0311) : 2/9/2016 3:37:29 PM (GMT-7)

Posted 2/9/2016 9:58 PM (GMT 0)
If I had to choose, I'd go with JHU for the definitive reading on the slides since that's what they specialize in.

Re your PSA, it can be somewhat variable so perhaps that explains at least some of the 1 point difference. And if your treatment path was like mine, there was no shortage of poking and prodding up there so that could be another variable. Those are just guesses on my part, however.

And while you were being good not to use your prostate before the last PSA blood draw, you may want to start using it now. I'm sure everything will work fine afterwards, but you probably won't have much ejaculate going forward. That's not necessarily bad, just different.
Posted 2/10/2016 2:58 PM (GMT 0)
Question here,

0311 said his PSA increased a full point, cancer on the move. When a Gleason grade is a "4", primary or secondary, is PC known to have a significate risk of travel outside of the gland?

The reason I ask, want to understand my AS risk of hitting such a status point.
_____________________________________________________________________________________
OCTOBER 2015
Age: 59
PSA: 3.0 elevated to 3.5 in (6) months
3T-MRI: (1) lesion identified
Fusion Biopsy Results: Lesion cores benign, additional (12) cores = (1) positive, cancer <5%
Pathology Summary: Grade Group 1 (GS6:3+3), 2nd pathology verification
Clinical Stage: T1c

Genetic DNA Profile: Above average risk for Aggressive PC (deCode Genetics)
Existing Cancer DNA Profile: DNA risk unknown (Oncotype DX test cannot be performed, <1mm)
High Grade Biological Score: 27% aggressive risk (Mi-Prostate Score)
Other Health Conditions: Diabetes Type II (DX 2000), on meds & insulin

PCa Treatment: "Active Surveillance"
Risk: Undetected Cancer Progression
Risk Likelihood: LOW

My Story: https://www.healingwell.com/community/default.aspx?f=35&m=3528051

Post Edited (NewDay) : 2/10/2016 8:02:51 AM (GMT-7)

Posted 2/10/2016 3:09 PM (GMT 0)
NewDay,

We've talked about this question a lot, and my understanding of the research consensus is this:

G3 cells do not usually change into G4 cells. Which is the basis of Epstein's comment that "G6 never does anything". However, G4 cells can spontaneously arise (or show up on a later biopsy having been there all along). And, evidence suggests that G4 cells CAN turn into G5 cells, and G4/G5 cells can metastasize.

What that means is that your AS protocol might show a G4 in the future, or it might not. If it shows up, then you'll have to deal with it. With your initial numbers, youi've got a great chance of never seeing a G4.
Posted 2/10/2016 3:35 PM (GMT 0)
Thanks halbert,

I noticed in your history signature, you made a decision to have aggressive treatment based on a G3 condition. Then the Post-op score had a G4 revision, making your original decision in-line for aggressive treatment.

Outside of having ESP, could you share the original decision reason given a G3 condition. Maybe it was the volume of cancer?
Posted 2/10/2016 4:45 PM (GMT 0)
NewDay-

Klotz believes that there's still plenty of time to treat when Gleason pattern 4 predominates in a biopsy core (GS 4+3). So in his AS protocol, which is the longest running one, patients can wait for that benchmark.

Tumors certainly may progress or spin off new tumors of higher grade, and that's true of tumors of any grade from GS 3+3 on up. However, some never progress or remain indolent for a very long time. We don't yet have great tools for predicting which are the indolents and which are the progressors, but we know if we just watch them closely, we can always catch them before any become dangerous.

- Allen
Posted 2/10/2016 7:44 PM (GMT 0)
TA, your feedback is greatly appreciated.

When I read a history such as 0311, it makes me question my AS treatment decision. Knowing the historical data of a AS G4 progression, suggests resulting corrective action will still have the same survival impact, is comforting. And yes I know, there are always exceptions.

0311, did not mean to derail your orginal thread. The posts, generated a few questions on AS that have been bothering me.

My apologizes.
Posted 2/13/2016 4:12 AM (GMT 0)
This is interesting. I also have two path reports. The original from Alta Bates in Berkeley had 3 of 14 positive at 25%, 45% and 75% (at the left apex) all G3+3=6. The also noted another core had microfocal involvement. One sample of the 14 was messed up.

The review was done at UCSF where I'm having my treatment. They graded the micro focal involvement as 8% G3+3 and increased two of the other cores to G3+4, but said only 10% of the cancer cells in those 2 cores showed G4.

What is the thinking as to what difference it makes how much of the tumor is G4 as opposed to G3? The UCSF surgeon suggested that 10% G4 was quite a low portion and less worrisome than if it were more.
Posted 2/13/2016 6:12 AM (GMT 0)
rainwest-

There's a reason many of us recommend a second opinion from Bostwick or Epstein only. They pretty much wrote the book, or at least are the continuing authors of Gleason's book. Their labs have a well trained staff of pathologists who do nothing but read biopsy slides. Can you say the same for the pathologists who read yours?

It may make a difference to you (and to many doctors) if you are considering AS, although NCCN thinks AS is still an option if GS3+4 is the highest and there's cancer in less than half the cores (with your stage T1c and PSA under 10). Otherwise your "favorable intermediate risk" PC has almost the same prognosis and exactly the same treatment options as "low risk."

- Allen
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