Should perineural invasion (PNI) influence active surveillance and radiation treatment options?

Tall Allen,
Those are interesting results even though there is a lot of uncertainty.

In my case I did have PI in one core of my biopsy where the biopsy core was identified as Gleason (3+3) and confirmed by Epstein. I take it that it means that the Pca cells involved in the PI are Gleason (3+3) and so it seems that might mean these are more aggressive type of Gleason (3+3). ?

BUSMAN-

Yes, PNI together with high volume of cancer suggest a more aggressive than usual low-risk subtype. Fortunately, you had SBRT, which delivers a much higher biologically effective dose than conventional IMRT, and they treated a margin outside of the capsule to get any EPE that may have occurred.

island time-

A few years ago, Epstein et al. at JH put together tables where, if you had biopsy-detected PNI, you can see the odds of the cancer being outside the capsule, using PSA, Gleason score, and the % cancer in core.

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4659365/table/T3/

12 core biopsies show PNI? So we would already know about that after biopsy?

Does a second opinion from somewhere like JHU rule PNI out?

What was interesting was learning that, presumably, a Gleason 6 ONLY tumor could grow forever in the prostate area and never spread to other parts of the body. Oncologist explained that. But that seems contradictory to many things I’ve read. He said G6 would remain G6, just like basal cell carcinoma would never become life threatening melanoma. That analogy made us feel better.

But then I read otherwise last night—that G6 has been know to shift gears and become more aggressive.

Such a confusing situation when everyone says you have to figure out for yourself what to do.

Tall Allen said...
...
A few years ago, Epstein et al. at JH put together tables where, if you had biopsy-detected PNI, you can see the odds of the cancer being outside the capsule, using PSA, Gleason score, and the % cancer in core.

/www.ncbi.nlm.nih.gov/pmc/articles/PMC4659365/table/T3/

Interesting. That table puts me at 87% probability outside the capsule (cT3a, G9, 100% of 2 cores, <10 PSA). MRI suggested that too (hence cT3a), with suspected neurovascular bundle involvement. Those factors were a big part of my selection of radiation and ADT as the plan for my very high risk case. We did the pelvic lymph nodes too (to 54 Gy), and a margin of 6mm around the prostate (4mm next to rectal wall) to 79.2 Gy. Happily, no major issues from all of that!

Stray said...
12 core biopsies show PNI? So we would already know about that after biopsy?

Does a second opinion from somewhere like JHU rule PNI out?

What was interesting was learning that, presumably, a Gleason 6 ONLY tumor could grow forever in the prostate area and never spread to other parts of the body. Oncologist explained that. But that seems contradictory to many things I’ve read. He said G6 would remain G6, just like basal cell carcinoma would never become life threatening melanoma. That analogy made us feel better.

But then I read otherwise last night—that G6 has been know to shift gears and become more aggressive.

Such a confusing situation when everyone says you have to figure out for yourself what to do.

Maybe a bit of "play on words".....by a doctor who knows what's he's saying...and not saying....in order to achieve a desired effect. Meaning....sometimes we can say things that are half true and not fully true...(studies show that doctors do this often)....it can be human nature.

"A G6 would remain G6, just like basal cell carcinoma would never become life threating melanoma". True statement. But a half truth.

It's like saying a catapillar will never fly. A factual and true statement. It's the butterfly that flies...but we'll leave that part out. And some catapillars never become butterflies. So if one were so inclined...one could state that catapillars never fly...and in their mind...they've told the truth. (In alot of people's minds....that could be seen as being dishonest....even though they told the truth)