On AS - Question around latest Biopsy Results

I've been on AS for four years with PSA rising from 5.8 four years ago to 7.4 at present, two previous biopsies showing 1/14 cores at <1% G6 and 1/17 at 5% G6 and two mpMRIs which were all clear. Last month in my 3rd MRI, a had a sizable (19mm) PiRads 4 lesion show up in the transition zone which led to a 3rd, fusion biopsy.

I received biopsy results over the phone but haven't seen pathology report nor spoken with my Uro. He wants to cover them in person when I meet with him next week. What came back is 2 of 17 cores were G6 but they constituted a large percent of those cores, like 90% and 65% and sounded like were from the lesion in the transition zone.

Obviously, I'll learn more when I meet with Uro, but going into that meeting, I'm wondering if AS is still an option? On the one hand, only 2/17 G6 but on the other, a large percent of those cores were G6. As always, any thoughts are greatly appreciated.

Thanks Jack.

I've now seen the report and its actually 5 of 17 cores G6 (the person providing results had said 2 of 17). All 5 positive cores are from the targeted lesion in the transition zone. The 12 systematic cores taken from around the prostate are all benign.

This is a different picture for sure. My guess is given that the transition zone is deep, it likely was never hit on prior two biopsies and I guess hasn't spend much from there so far. Hearing this, I'm thinking AS may no longer be the right option.

My situation may be similar to yours, I get my biopsy results on Monday. I thought that it would take some Gleason pattern 4 to get me off AS, but if my biopsy results are G6, I may be forced to reconsider. My red flags are a PSA density of approx .35 (<. 15 required for JH AS program) and a 12 x 24mm PIRADS 5 lesion in the TZ plus a 14mm PIRADS 4 lesion in the PZ.

Your TZ lesion must be quite large if they took 5 targeted cores. The fact that your previous MRI was clear is also something to consider.

Were your MRI's 3T and was the biopsy fusion guided?

Can a G6 lesion in the TZ grow at that rate in a year? What are the risks of waiting another year for another biopsy? I think I would still want to see some pattern 4 but it's a tough call and may not be as easy as G4 or not G4.

I think it may come down to your own comfort level with your situation. It's a tough call and I don't think there is a right or wrong decision. Good luck.

Thanks to all for responses.

Astronut,

Although my first MRI 4 years was negative, "no suspicious lesions" and "no prostate cancer seen", it did note that there were "rounded areas of T2 hypointensity in the transition zone, likely related to hypertropic changes" (i.e BPH).

My theory is that this lesion has been there for a long time. My first PSA ever at 50 was 3.9 and until now, there's never been a reason found for that. Two biopsies showed basically nothing and now this third, showed G6 in this lesion, but nothing anywhere else. That's likely because the systematic (vs. targeted) biopsies don't hit the transition zone which, btw, is known for having larger, less aggressive cancer, that throws off more PSA than typical PC.

So I think that what I might have (although no way of knowing for sure) is a sizeable, presumably slow growing, G6 lesion in the center of my prostate and not much anywhere else. The question is what do you do with that?

Rick,
There is little published info on transition zone tumors. what I have found is that they can go for quite a while and still be contained, because the TZ zone is in the middle of the prostate away from the outside margins. My TZ tumor was finally discovered after 10 years of searching and was still well contained even though it was a G4+3. The risks of surgery are higher with TZ tumors because the ureatha runs through it, increasing the risks of incontinence. With a G6 even with a high core % you should be OK for quite a while.

TZ tumors can grow fast, and they sometimes grow up the urethra, pushing up through the bladder neck where they can block urine flow. They can also spread into the anterior zone. If it is causing urinary problems you may want it removed by either TURP or prostatectomy. If it isn't causing problems, you can stay on AS, have radiation or focal therapy.

TZ tumors tend to be less aggressive, and only 2 cores is pretty minor. If it's not in your way, why treat now?

Based on my latest biopsy results, my Uro recommends surgery. His view is that although only G6 has been found and really only in this one lesion in the transition zone, because there were 5 cores with 20% to 90% positive and the lesion is large (19mm), he feels that surgery is warranted. He says I don't have to rush but I should come off AS. He believes I'm in a very favorable position with only G6 in the center of the prostate which didn't show up any other part of the prostate, so surgery is very likely to provide a cure. He said because I'm young (at 56) and healthy, odds for good recovery are high.

In researching online, I wasn't able to find much regarding a large G6 tumor. I'm thinking my situation is a bit of an uncommon one -- only G6 but a sizable amount of it. I was prepared to leave AS if any pattern 4 showed up but stay on it until then. I can see the benefits of surgery now in line with what my Uro laid out but wonder if its more than I need.

Yes Jack, your interpretation of my May biopsy is correct -- all 5 positive core were from the targeted lesion and the 16 other cores taken systematically around the prostate were benign. When my Uro stated that AS guidelines call for no more than 3 cores positive and no one core < 50%, I challenged that saying the results seemed more like 1 of 17 areas of the prostate showed positive cores vs. actual results at 5 of 21. His counter was that one positive core was 13mm at 90% which is a half an inch. He saw that as large

I did read an article that stated that sometimes large less aggressive tumors can turn aggressive but that was just a statement in some article not a study.

So, you're right about the general consensus on when to move from AS to treatment (based on expert panel AS recommendations LINK).

* 3+4 is fine continuing on AS as long as the volume of Gleason pattern 4 is low (≤10% of total tumor)...but this is not your case
* A "high volume" 3+3 case is an indicator of disease progression and of the need to consider active treatment...but a clear biopsy criteria for defining "high volume 3+3" has not been established

Obviously, my previous question was trying to help you establish whether your 3+3 tumor is "high volume" or not.

The mpMRI is often useful in identifying higher volume tumors. Was there information on tumor size from your April mpMRI? I'm with ya on what you said "I can see the benefits of surgery now in line with what my Uro laid out but wonder if its more than I need," and am just trying to use available info to see where you fit.

Post Edited (JackH) : 6/6/2017 11:44:51 AM (GMT-6)

Jack, I think you're right on the key issue -- for purposes of AS, do I have "high volume" G6 or not? On the last biopsy, none was found beyond the tumor but the tumor was sizable. To answer your question, the mpMRI identified the lesion size at 19mm.

With a PSA of 7.4, to date my worry was there a higher grade cancer that just hadn't been identified. Because TZ tumors are supposed to throw off more PSA than other areas, I assuming this 19mm tumor is responsible for the elevated PSA.