Weird case- invasive gleason 6

Hey guys (and gals), I am a wife posting for my husband. In case you remember me from previous posts, in January my 45 year old husband was diagnosed with very low risk Pca, PSA 1.9 and 1 core out of 13 cores 15% 3+3 in the transition zone at MRI targeted biopsy, super low Oncotype GPS score of 12 . AS was an option that was discussed, but my husband really wanted to do the right thing and be proactive so he decided to go under the knife and get a RALP. The final pathology came back and the doctor called to inform us the good news was he remained a G6 after surgery, the bad news was there was a positive margin at the bladder neck. So although the positive margin was not good... the G6 meant to us that even if he does have a BCR , SRT should take care of it. Because G6 does not metastasize, right?

After surgery, He had a great recovery... NO ED whatsoever (no ED meds needed) and very minimal stress incontinence. We were loving life, traveling to Italy 6 weeks post op and he was feeling great!

Well this week was the first post-op appointment with the surgeon. I came prepared with a list of questions... I learned that the tumor had invaded the ENTIRE anterior portion of the prostate. Something like 3.8 cm in diameter. There was extensive infiltration of the bladder neck... It was one of those " we have never seen this before" situations. He mentioned the tumor had actually invaded the muscle at the bladder neck, which is something gleason 6 is not supposed to do.

Not very comforting.... I am going to have the specimen sent to Epstein for a second opinion. I feel like they are missing something... This was all done at a center of excellence , UCLA... but considering the odd case I want another opinion.

Has anyone else had a high volume gleason 6? Positive margins with G6?

One bit of good news- First PSA came back as <.01

Leah77 said...
Has anyone else had a high volume gleason 6? Positive margins with G6?

My prostate was (4.5cm length) x (3.6cm width) x (3.5cm thick), so total (56.7 cubic cm). I had 30% involvement, mostly in right side, focally in left. So I very likely had a big chunk of cancer just like your husband did. Mine was (3 + 4 = 7) but the gleason 4 part was very small. So probably very similar to your husband's prostate.

My one margin was 3mm at right lateral. My Epstein 2nd opinion scored margin at (3 + 3 = 6).

I went 5 years totally undetectable on uPSA. Then it showed as mid .020s in Feb 2017. Have been tracking my uPSA about monthly, and recently it's been about mid .030s, at about 2.5 years later. So something to watch, but not sure where mine will go in future. My theory is my gleason 6 margin bit of tissue is just sitting there, doing not much, and I hope I can just outlive it without further bother.

Your husband may have a similar outcome. You definitely need to get Epstein to score the positive margin. If that margin is all that remains of the bladder neck invasion, and it (the margin) is truly gleason 6, you may not need to do anything for a while, maybe forever. Even if it does grow and produce uPSA, that does not mean it will metastasize outside the (former) prostate area. It could (very likely) stay local. But you won't know for some time. You would be well advised to watch uPSA about quarterly for the long haul, and be prepared to hit it with SRT if it does start getting out of control and uPSA really does spike up and up. If it does spike, or if at age 45 he just feels adjuvant SRT now is the way to go, your docs will likely agree on it.

Not sure about your comment about gleason 6 not supposed to invade outside prostate. Locally advanced and metastatic are not the same. Your husband may have had locally advanced PCa, but not metastatic. See this from the cited paper:

"Locally advanced prostate cancer has extended clinically beyond the prostatic capsule, with invasion of the pericapsular tissue, bladder neck, or seminal vesicles, but without lymph node involvement or distant metastases. It is referred to as T3–T4 N0 M0 prostatic cancer."

https://www.sciencedirect.com/science/article/pii/s2214388215000259


And here is another publication that give you info about BNI:
https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1464-410x.2009.08957.x


Yes, get the Epstein ruling. Make sure Epstein provides the gleason at the one margin. And, of course, make sure this is the standard PCa cancer, and not the rare type that puts out low PSA even when growing wildly. It does seem odd about his 1.9 PSA and minimal biopsy cores, then having such a large amount of PCa on path. But maybe just because he is young, and biopsies can miss a lot. So that's probably not an issue.

I think the first uPSA at <.01 is really, really good news, and hope the best for you both.

Robert

Yes, G6 is indolent as it doesn’t progress to more aggressive strains that become metastatic. However it can grow in the prostate area and cause problems. One of our members several years ago had G6 that was growing and bulging in a way that caused bowel problems. G6 can not live outside the prostate area, but it can develop enough tumor mass that it causes problems. Thankfully most G6 men never experience these issues.

Leah, you are prudent getting further investigation of the tissue. You are in a situation, as Bobiesan says, that you have to monitor the disease and be prepared to treat as necessary. Most likely you are in a management situation and will never have PCa advancement that is threatening.

Oh yeah. I remember what my thinking was at JH.

One was...”I can’t make this decision on the spur of a moment like this”.

Two was...”I had a stricture. I know there’s scar tissue in the urethra. I’ve heard scar tissue/strictures/rad don’t always mix well. I think I want to be sure.”

I think that bouncy ball was mainly on black and white tv. (Least that’s how I remember it in my head anyway).

And I remember you. You did a lot of good research.

(So far, i’d call it a success “mostly”. Less than .01 is as good as it gets.

Island time, when you sent your slides to Epstein, what was the turnaround time? Were you able to consult with him by phone? Or do you just get a report?
Jasper, I’m so sorry about your dad.
Yes, I’ve also read that pathology is highly subjective, which is why I’m getting a second expert opinion.
Also, something to mention; The guidelines for determining Gleason scores have changed several times over the years. A lot of cases that were called a G6 would be labeled as G7 today. The most recent changes were in 2014. Perhaps your dad would today have been considered a G7.

Leah, i sent my biopsy slides to dr Epstein and called about 4 - 5 days later. The results were available and they faxed them to me that day after receiving a form I had to sign.

The next day I called and he took my call, was very gracious with his time and we spoke for about 10 minutes

I have sent emails to him and always got a response the next day. Just recognize that he is very busy, so be to the point with him. He is very professional and gracious and provides great clarity in his communications.

Mumbo said...
I asked the pathologist I talked with why there would be such a difference between the hospital pathology (4+3+5) and their pathology results (4+5)... So in my case, I should be looking at it as a G9 and not a G7 even though the differences may only be in the percentages estimated of a predominately grade 4 cancer.

I think it was Tall Allen that explained to me that Gleason grading is 1) the first number is the most predominant cell type by volume, as most of us know, and 2) the second number is the highest grade of the cell type that are lower in volume than the primary score.

So in your case of 4+3+5, your percentages of volume may have had a larger volume of grade 3 and a very small percentage of grade 5. A "regular" pathologist would place the grade 3 second, though the smaller volume of grade 5 cells qualifies to take the second position, being higher grade than the more voluminous grade 3 cells.

Make sense? At least, that's the way I remember it.

JNF explains it the way I understand it also. My RO says any Gr 5 is a problem in his mind and my G7 had tertiary Gr 5 even before the second opinion.

My post RP pathology was upgraded to 8 (4+4) with focal areas of 5. My Uro said I might as well consider myself a G9. Wonderful.

Herophilus said...
Good luck palindrome... (mattam) that's unfortunate.
Hero

Ditto.

IT

mattam said...
Lol guys. Most of my luck ran out four years ago with failed RP and RT. But your wishes are still appreciated.

Slow Internet here

lol

The analogy I like for how Gleason 6 disease is different in kind from higher-grade cancers is that, while both can spread, Gleason 6 disease spreads like crabgrass while Gleason 9 spreads like dandelions. Crabgrass can grow under your azaleas where it is hard to pull up but it won't pop up in your back yard because the wind has spread the seeds all over the place. When surgery misses a bit of Gleason 6 cancer it's fairly easy to go after it in a follow-up procedure because you know more-or-less where it is.