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What Do You Do When Your 2nd Opinion Is Different From Your First

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Posted 3/23/2019 3:36 AM (GMT 0)
what do you do when your second opinion is different from your first. i sent in a request for my pathology report to john epstein at john hopkins. today i received the results and here's what was written:

A. benign fibromuscular tissue.

B. PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3+3=6 (GRADE GROUP 1) DISCONTINUOUSLY INVOLVING 80% OF ONE CORE

C. PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3+3=6 (GRADE GROUP 1) INVOLVING 20% OF ONE CORE

now take a look at my first report and tell me what you think.
==============================================
D.O.B. | 1973

08.22.2018 | 3T MRI
08.23.2018 | 3 peripheral zone focal abnormalities, 1 PI-RADS 4 lesion and 2 with PI-RADS 3 lesions. No extraprostatic disease, pelvic lymphadenopathy, or enhancing pelvic bone lesions.

02.25.2019 | MRI/Ultrasound Fusion Targeted Biopsy
02.28.2019 | DX @45 with Gleason 4+3=7

A. PROSTATE, LESION 1, LEFT APEX, 3:00, 3D MRI FUSION NEEDLE CORE BIOPSIES:
*BENIGN FIBROMUSCULAR TISSUE.

B. PROSTATE, LESION 2, RIGHT MID GLAND, 10:00, 3D MRI FUSION NEEDLE CORE BIOPSIES:
*PROSTATE CANCER, GLEASON SCORE 4+3=7 (GRADE 3) INVOLVING 3 OF 3 CORES (95% DISCONTINUOUS, <5%, <5%). GLEASON GRADE 4 INVOLVES 60% OF THE TUMOR. PERINEURAL INVASION IS PRESENT. CHRONIC INFLAMMATION.

C. PROSTATE, LESION 3, DIFFUSE LEFT MID GLAND, 3D MRI FUSION NEEDLE CORE BIOPSIES:
*PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3+4=7 (GRADE GROUP 2) INVOLVING LESS THAN 5% OF THE FRAGMENTED CORES. GLEASON GRADE 4 COMPONENT INVOLVES 5% OF THE TUMOR.
Posted 3/23/2019 4:17 AM (GMT 0)
The formatting is difficult to read on your post, but if I'm reading this correctly your first report has THREE G7 (4+3) cores and ONE G7 (3+4) core. JHU came back with only TWO positive cores and they were both G6 (3+3). If I'm reading that correctly, that's a huge difference that is significantly beyond the differences we typically see here with a second opinion. (Anecdotally speaking.)

In my non-medical opinion, the difference is significant enough that you need to get some confirmation here. From what I understand, Epstein at JHU will do a phone consult...I would start there and ask him how his lab could have such a significant difference from the original pathologist's report. Based on your first opinion, you need to choose a treatment. Based on your second opinion, you could go on AS.
Posted 3/23/2019 5:05 AM (GMT 0)
JH is considered to be the gold standard for this. I'd go with the Epstein report (he wrote the book on how to do this).
Posted 3/23/2019 9:51 AM (GMT 0)
Like Michael said, it might be of value to set up a phone call with Dr. Epstein. He IS considered the best at this. And, this one makes a difference in what you do. AS is a real option for you--and the good news is, with AS the "Active" is for real.

You'll do another biopsy, MRI guided etc., and do other things to keep track.
Posted 3/23/2019 12:01 PM (GMT 0)
Thoughts on what to do next (in no particular order).
1. Talk to your urologist.
2. Get a third opinion.
3. Ask the first pathologist to take another look to see if they made a mistake.
4. Talk to Epstein.
5. Take your time and be deliberate.
6. Remember the old axiom: "Act in haste; repent at leisure."
Posted 3/23/2019 12:12 PM (GMT 0)
Clearly call Dr. Epstein. I have had occasion to communicate with him via e,mail and found him to be very responsive and easy to communicate with.

Actually, the difference isn’t much. They agree on the extent bob the discontinuous sample just are mot together on the G4 aspect. Discontinuous basically says the sample broke apart and was in pieces. Your first is picking up a very small amount of G4 in two samples that JH did not.

Remember the difference between 3 and 4 can be very subtle and that is where Epstein experience can be very meaningful. He does more than 10,000 prostate biopsies a year for many many years.
Posted 3/23/2019 12:48 PM (GMT 0)
I know the feeling... I agree that you should chat with your urologist about the results having a pretty good understanding that there is no reason to rush anything at this point based on the MRI and two pathology reports. If the urologist pushes you to do something, just take your time and see other doctors for their take on if and what treatments or surveillance are best for your situation. You do have PCa so you did find the correct forum and the right people to chat with.

I view your data being pretty consistent, three lesions with one benign, one with a fair amount of cancer, one with a much lessor amount. The main difference is the classification of some of the cancer as 3 or 4 which is where JH probably has the better resume for making that call.

I called JH-Epstein and he was out-of-office as to be expected with experts but I did chat with the pathologist listed on my report which was very informative and helps frame their position on what they saw. It might be a difficult call for a pathologist which they can explain.

You will probably have all options available to you from surveillance to excessive treatment options so take it slow and steady working towards the best solution for you. That is good news.
Posted 3/23/2019 2:24 PM (GMT 0)
I agree with the others a phone conversation would be helpful. I called Epstein’s office at 7:30am and got him on the phone, he was gracious with his time.
My local pathologist had me at G8(3+5), Epstein downgraded me to G6 (3+3), disagreeing with the premise used to call my cells grade 5. My surgeon said Epstein is the gold standard. I was ultimately upgraded to G7(3+4) after surgery.

I eventually got a 3rd opinion at MSKCC and they agreed w JH
Posted 3/23/2019 2:37 PM (GMT 0)
I would choose active surveillance. This requires another biopsy in about a year. You can then send the result to Epstein again and maybe the pathologists do no longer disagree.
Posted 3/23/2019 10:34 PM (GMT 0)
Getting back to this, it seems like there are two differences between the two reports. First, a downgrade from G7 to G6, which is not all that unusual. But if I'm reading both reports correctly, you also went from four positive cores to only two. So two positive cores went from G7 to "all clear." That's the part that I would want to dig in on...
Posted 3/24/2019 11:42 AM (GMT 0)
A 3rd opinion from Victor Reuter at MSKCC is an option or wait until the next biopsy. Some G4 is a worry--don't ignore it but remember that surgery/radiation are big steps not to be undertaken lightly.
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