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Posted 6/30/2016 2:36 AM (GMT 0)
Hi folks!

My absence for the past several weeks is just a continuation of my life of denial, I guess. That and a bunch of follow-up consultations, new tests, and now imaging results. For the general backstory, please check the signature profile below (sorry, I'll update it with the latest after this post).

The short version is that I'm 73 with high volume G6 in a small prostate with history of previous TURP procedures (1992 & 2002). Consults have so far allowed me to maintain hope for AS strategy. Most recently a) new PSA was done showing drop to 4.0 from 4.3 in Jan.), and b) MpMRI done at Oregon Health and Sciences University showed PIRADS 5 index lesion. I'll put the key points of that report below.

So my main question is: Can I really continue my life of denial? More specifically: Does that PIRADS 5 mean that I for sure have a G7 or more tumor? Or do I have to get a new (targeted?) biopsy to be sure?

I'll leave it there for now. Totally love this forum! Of course, the main thing that's kept me from posting for so long is that I can read and search so much that's useful quite without getting all specific and personal.

Thanks hugely for being there!

Here's that MRI report:


EXAM: MRI Prostate with and without intravenous contrast.

HISTORY: Prostate cancer. PSA 4.3. TRUS guided biopsy 3/1/18 positive for
Gleason 3+3 and 6 of 6 cores.

COMPARISON: None.

TECHNIQUE: Endorectal multiparametric and multiplanar MRI of the prostate
performed, including axial T1 images of the pelvis and high resolution axial
T2, diffusion, and perfusion pre-and post dynamic intravenous gadolinium images
of the prostate.

FINDINGS:

Prior TURP changes within the prostate.

The prostate measures 4.3 CM transverse by 2.5 CM anteroposterior by 4.4 CM
craniocaudal, giving a gland volume of 16 mL. No post-biopsy hemorrhage noted
on T1 weighted images.

Probable prostate tumor focus identified in the left mid peripheral zone, 8/23,
measuring 1.3 CM transverse by 1.7 CM anteroposterior by 1.7 CM craniocaudal,
giving a tumor volume of 1.3 mL . The tumor demonstrates low T2 signal,
restricted diffusion and dynamic contrast-enhancement abnormality. Overall
P
I-RADS classification 5.

With respect to tumor stage:
Ill-defined continuity of the left prostate capsule could represent extension,
8/22.
Likelihood of left-sided extracapsular extension: Indeterminant (40-60%).
Likelihood of left-sided seminal vesicle invasion: unlikely (20-40%).

No lymphadenopathy, suspicious bone lesions, or other abnormality identified.

IMPRESSION:

PI-RADS 5 tumor focus in the left mid gland peripheral zone. Possible left
sided extracapsular extension. No evidence of left seminal vesical invasion.




Whippoorwill
Posted 6/30/2016 5:18 AM (GMT 0)
No, a PIRADS 4 or 5 does not confirm that you have a high grade cancer. There are HPGIN and atypical cells, as well as benign lesions that can score that high.

The PIRADS system rates the liklihood of cancer being found on a subsequent biopsy. It is not 100 percent certain, not even close.

You must now have a fusion/targeted biopsy, as the question has been raised, and you will not be relaxed until you read that report. Stop panicking and just schedule that biopsy.
Posted 6/30/2016 6:24 PM (GMT 0)
AS is not denial - it's closely watching indicators with the idea of having treatment when the red flags go up.

I agree with ASAdvocate - you have to have a targeted biopsy now, and if it is GS 4+3 or higher, you must consider radical therapy. If it is below that threshold, you can consider staying on AS.

- Allen
Posted 7/1/2016 6:36 PM (GMT 0)
Great responses, as usual! Much appreciated, as always. My "in denial" remarks were mostly tongue in cheek. But, wow, the Uro Docs can sure imply that denial is in place once one runs moves beyond the most ideal qualifications for AS but still wants to go that route. The PA who called yesterday about the Radiology report provided above as much as told me that I need to move ahead with treatment. My request for another well known radiologist to give me his reading was reluctantly responded to with the equivalent of "We'll see" and, "You really need to move on with treatment anyway given that predicted ECE."

What do you think in that regard, by the way? I was surprised and disappointed to get little more than a Partin Tables-like probability range. Maby I was just too optimistic as to what MpMRI could detect? Or do I have stronger grounds for getting that further reading I requested?

Again, thanks for all the help!

Whippoorwill
Posted 7/1/2016 8:17 PM (GMT 0)
What do you hope to get out of another opinion that would in any way change your next step? You need a targeted biopsy.
Posted 7/2/2016 3:09 AM (GMT 0)
Thanks, TA,

I do agree that a targeted biopsy is needed. What I'd hope to get from another radiologist opinion, however, is something more than that vague 40-60% ECE estimation. If ECE is very likely then I should give RT first priority for my radical therapy route. Almost(?) even without needing to know what that PIRADS 5 stuff really is. If ECE is highly unlikely, and I need to proceed, then I figure RP makes sense ... but if that's the case I'd really want to know about the PIRADS 5 area because AS may still be at least semi-reasonable. Am I way off track here?

The OHSU radiology cohort includes Dr. Fergus Coakly, who seems to be one of the major figures in MpMRI prostate imaging. I'd like to get his opinion as to the adequacy of the images and their interpretation.

Thanks,

Whippoorwill
Posted 7/2/2016 5:18 AM (GMT 0)
Whip,

Whatever you do, please keep us updated. IMHO, you have an interesting case with that much G3+3 plus the PIRADS 5. If the biopsy comes back with more G6 and HGPIN, then it will be of great interest as to what advice you get from the specialists. I just heard one urologist say that he will not operate on patients with only G6, as he considers it non-life-threatening. So, please keep in touch.
Posted 7/2/2016 2:47 PM (GMT 0)
Whip, sorry for the news with the mri and biopsy. Good luck with the targeted biopsy as it seems that is your next step. I never thought of having another radiologist read my MRI but I knew I was getting treatment regardless so I can understand your reasoning with the ECE probability finding being so important.

Now by no means am I anywhere near as educated on prostate cancer matters as some here but I agree with the concern of the amount of cancer that may be in your prostate and the chance of ECE being there. Whether it is 3+3 or not would seem to matter less if it is close to breaking out. I've read enough of ASAdvocates posts in the past, and I don't think he would necessarily agree with the comment that he attributes to one Urologist. I don't know how anyone can think 3+3 is non-life threatening if it is ready to get out of the prostate. If you have high volume it would seem that it has been growing quite a bit, over what time frame, who knows?

Now I am not trying to get you to worry more then you are but I am just agreeing with your assessment that this should be taken very seriously and you should gather as much info as you can and proceed to get different opinions as to the best treatments available for you. Of course your age is a factor but in the long run only you can really assess what treatment will be right for you.

Best of luck Whip and please keep us posted as you gather more information....Jim
Posted 7/2/2016 6:15 PM (GMT 0)
Thanks, ASA, I will keep posting updates. I think you are correct about my interesting G3+3 high volume situation. It also seems unusual to have had two prior TURPS (@ age 49 & 59) for BPH. I find it possible to imagine that I just have a weird smallish prostate that is now in phase 3 of a mostly innocent pattern of misbehavior. I know, of course, that BPH cell changes are quite distinct from PC but ....
In any case, I, too, have seen the arguments for regarding Gleason 6 as "innocent." The question mostly seems to be whether it might hide 7+ or evolve into 7+.

Jim, Thanks for your thoughts as well! At age 55/6 I'm pretty sure
I'd be looking a lot harder at treatment, too. And I agree with you about the importance of knowing re ECE. I've been told that G6 does not wander out but a) there doesn't seem to be full agreement on that and b) if that PIRADS 5 area is 7+ then it could go out for sure. Hence the need to know more.
You are certainly also an interesting outlier, BTW. Quite a few positive cores though not so many as mine, for one thing. And that NIH trial. You have probably posted other particulars elsewhere, right? I'll do a search.

Thanks all!

Whippoorwill
Posted 7/2/2016 6:19 PM (GMT 0)
Thanks for explaining your concern about ECE. I'm unclear about the "vague 40-60% ECE estimation." Was that based on a nomogram, or was that something in the radiologist's report? If it was in the radiologist's report, I assume it is vague because there was only a microscopic focus of cancer at a certain place. Even the best MRIs are only able to discern cancer down to a size of maybe 2-4 mm if everything went perfectly. Anything smaller than that, errors due to the signal-to-noise ratio, movement, and voxel size overwhelm the ability to read anything. ECE is particularly problematic near the apex because the prostate capsule disappears there, so there is no clear border.

Sometimes they can biopsy through the capsule in the questionable area. Then, if the pathologist finds cancer mixed in with the muscle or other extraprostatic tissue of the prostate bed, that can add to the certainty that there is focal EPE. You can request that the urologist try to do this, and ask that the pathologist report on it (I know Bostwick and Epstein will report infiltration, but other pathologists may not).

- Allen
Posted 7/2/2016 9:06 PM (GMT 0)
Hi again, TA. Always great to have your input!

The 40-60% ECE estimate comes from the radiology report. That portion of my first post above is a direct copy/paste, in fact. It really seemed, though, that the report just repeated what the nomograms said before any MRI.

I agree it's more likely that they didn't/couldn't get a better determination. You provide a helpful explanation as to why that might be. Reader skills are just so often said to be crucial to getting the best interpretation that I don't want to miss any chance to get the best possible interpretation.

Your further points regarding special biopsy possibilities are especially helpful. I may have trouble locally getting even a good targeted standard biopsy. So I may well want to get back to OHSU for the kind of approach you suggest.

Whippoorwill
Posted 7/5/2016 3:41 AM (GMT 0)
get mp3TMRI guided biopsy from Dr.Busch, in Chattanooga, considered one of the best if not the best in reading MRI, in US, or at least get him to review your MRI CD for $200 fee, there is no other doctor so experienced and dedicated to his patients
Posted 7/5/2016 1:35 PM (GMT 0)
Thanks for that, ao. I know that so much depends in the expertise of the reader so I'll keep your suggestion in mind.

W.
Posted 7/6/2016 1:14 AM (GMT 0)
For Tall Allen, especially:

I have just had an excellent exchange with the head radiologist and got some very good follow-up to that MpMRI reading. You will recall that you said the following:

Sometimes they can biopsy through the capsule in the questionable area. Then, if the pathologist finds cancer mixed in with the muscle or other extraprostatic tissue of the prostate bed, that can add to the certainty that there is focal EPE. You can request that the urologist try to do this, and ask that the pathologist report on it (I know Bostwick and Epstein will report infiltration, but other pathologists may not).

On the ECE topic here is what this radiologist said:

I might have estimated the chances of ECE a little higher [i.e., higher than the 40-60% of the original report--W.], but it is a somewhat subjective evaluation – interface on the left of the prostate (right side of image) looks a little irregular – see arrows of left versus right sides below.

[Image was provided at this point complete with arrows....but pretty hard for me to read on my I pad and I don't know what I'm looking at anyway--W]

His communication then concluded:

We could certainly do a targeted biopsy directly from the center of the left-sided abnormality, and see what we find. Of course, just because we could do it does not mean we should…

Had not heard of biopsy to detect ECE, do you have a reference?


So, TA, can you help me here? I'd like to respond with particulars but will definitely need you assistance.

Many thanks!

Whippoorwill
Posted 7/6/2016 1:47 AM (GMT 0)
Of course. Here are a couple from Epstein and Eastham (can't do much better than that!)

Should the involvement of skeletal muscle by prostatic adenocarcinoma be reported on biopsies?

Clinical Findings and Treatment Outcomes in Patients with Extraprostatic Extension Identified on Prostate Biopsy

- Allen
Posted 7/6/2016 2:07 AM (GMT 0)
Fantastic, TA!! How do you do it? That first one in particular seems right on target (pun intended?).

W
Posted 7/7/2016 4:24 AM (GMT 0)
Now, there is a risk to doing this intentionally (it's usually accidental) that you should be aware of before proceeding. Because all your cores were GS 3+3 and you scored low risk on Prolaris, it's probably not a big risk, but you should know before deciding. Please read the link below- the section on biopsies especially:

Can invasive procedures spread prostate cancer?

- Allen
Posted 7/7/2016 2:27 PM (GMT 0)
Yes, TA,

I hadn't seen that thorough review you'd done but had fairly clear understanding that PCa spread from biopsy, etc., was unlikely and also that G6 does not (almost for sure) ever metastasize. And it did look like those papers on biopsy and ECE were not suggesting intentional assessment by that method either.

It now seems possible that the PIRADS 5 location was sampled already with the initial TRUS biopsy, BTW, so I'll definitely see if that can be checked out and confirmed.

Thanks,

Whippoorwill
Posted 7/9/2016 10:53 PM (GMT 0)
My urologist who did the biopsy in March had this to say:

"I am fairly confident that the tumor was sampled, based on the fact that all 3 left sided biopsies were positive and there was left sided asemmetry on the ultrasound. However, the only definite way to know is another biopsy using MRI guidance."

So I'm inclined to request that new biopsy. Still sound reasonable? Or should I just jump ahead to start arrangements for EBRT .... since I'm getting: 1) Estimate that new MRI guided biopsy has 50+% chance of finding G7 or more. 2) My ECE estimate based on the original MRI is at 50% +/-. And 3) that original MRI even put SVI possibility at 20-40%.

I guess I'm starting to get a little tired of holding on to my AS hopes?

Whippoorwill
Posted 7/10/2016 3:19 AM (GMT 0)
Only you can answer that. There's no right answer, only a question of what you are comfortable with. But let me ask you a question:

If the biopsy fails to find ECE, will you stay on AS? If you answer "yes", then you need the biopsy. If your answer is "no", then why bother?
Posted 7/10/2016 11:46 PM (GMT 0)
Thanks yet again, TA,

My plan would be to stay on AS until something worse than Gleason 3+3 is identified or until ECE seems to be solidly confirmed. A new biopsy might find the higher Gleason though it is not likely to confirm ECE.

However, even that most recent and very encouraging "New" Prostate Cancer Infolink post regarding the European AS results would not seem to be suggesting AS for someone with my 6 of 6 positive cores at 60-90% involvement. I am thus stil open to the arguments for major intervention.

Whippoorwill
Posted 7/11/2016 12:10 AM (GMT 0)
Keep in mind that the European PRIAS had the strictest protocol around, modelled after the Johns Hopkins protocol. Both Johns Hopkins and PRIAS have since loosened up entry requirements. Current NCCN guidelines now say that "favorable risk" is the only entry requirement. The point at which Klotz now advocates leaving AS and getting treated is only when there is evidence of predominant Gleason pattern 4 (i.e., GS 4+3) on a biopsy.

- Allen
Posted 7/11/2016 4:54 AM (GMT 0)
Whip, TA's binary question about the biopsy finding EPE is crucial.

Have the repeat biopsy.

If I were you (and I could be at anytime), I would have my parachute packed and be ready to jump into intervention if the biopsy showed EPE.

A finding of <10 percent G4 would not change my course. The EPE (from what I know) would.
Posted 7/11/2016 3:54 PM (GMT 0)
For TA:
Good reminders on the PRIAS and NCCN AS guidelines. It's important that G 4+3 must be taken more seriously than 3+4.

For ASAdvocate:
Nice parachute analogy! I've had mine packed for some time now but I'm pretty content to stay in the AS plane as long as possible. Less fear of flying than of jumping?

On the ECE/EPE question:
Agreed that this is every bit as important as finding Gleason >3+4 (maybe even more important?). Unfortunately, it seems that for me the area suspicious for possible ECE doesn't make it easy to confirm or deny ECE by MRI alone. And the radiologist is not showing any interest in some possible(?) biopsy that specifically looks for ECE.

I plan to start efforts today to line up the targeted biopsy all the same. I'll keep you posted.

Whippoorwill
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