Just left MD Anderson consult...not what we expected

star0210 said...

Mumbo said...
Hi Star - Is this a correct understanding?
• Original 12 core biopsy and pathology was done in New Orleans area (3+3 all cores)
• 2nd opinion consultation and pathology review was done at MDA (4+4 one core)

If you assume you have some Gr 4 to deal with, the differences between 3+4, 4+3, and 4+4 are small but do make a difference in treatment options although many just treat to the highest number identified. Only you can decide whether you want to pursue a 3rd opinion on one questionable biopsy sample that a set of targeted biopsy samples in March will supersede and probably provide more definitive information since you are looking for something specific now.

Good luck with the waiting.

Yes, that is correct. We also had an OncoDX genomic testing in the interim which came back at 23% low risk. Any 4 was always our trigger point to treat. For surgery, it doesn’t matter whether it’s 3+4, 4+3, or 4+4. But it does matter if he were to choose RT as his primary treatment. Both our local uro and Dr Ward at MDA advise against RT. Dr. Ward feels fairly confident that it has not escaped the prostate based on pathology review and PSA level. I asked him if it HAS spread would he still recommend removal since we would be looking at RT anyway and he said if he is indeed a G8 then yes, he would still recommend removal.

This is extremely frustrating to me!

the guy is anti-radiation. that's the only explanation I can come up for recommending surgery for g8 that's likely out of capsule.

I just put some basic information from your signature into the Memorial Sloan Kettering Cancer Center (MSKCC) pre-surgery nomogram. This is probably the most significant PCa treatment database in existence. I guessed at the clinical stage as you haven’t mentioned it and used a middle of the road T2b.

Results include; probability of extracapsular escape=77%. Probability of Lymph node involvement=25%. Probability of seminal vesicles involvement=25%. Probability of progression free at 5 years=35% and at 10 years =22%.

These are indicative that due to the relatively high PSA at age 51 and G8 that surgery will most likely need salvage radiation. This is the worst combination as SRT side effects are far more significant than primary radiation treatment when the prostate is intact. Also the PSA increase in a very short time should be alarming.

See the ROs and take their assessments seriously. No surgeon can guarantee that the surgery will be successful. When you are high risk, surgery just doesn’t work as well and numerous studies will illustrate that. High risk dx also increases the probability that the doctor will not be able to spare nerves. Problem is that there is no way to know until the surgeon is in and there is no going back. In my opinion, you still need to do some more radiation assessments and get on with the decision. For cure surgery is in no way superior than radiation. In intermediate and high risk it is definitively less successful than radiation.

The RO facilities and docs at MDA are among the best. Our consult with Dr. Ward was disappointing. He was insulted that we were interviewing him for the job. My wife wanted nothing to do with him. She grilled him with some pretty tough questions and his attitude immediately changed to indifference.
But if you're a G8, I would lean towards RO, and MDA.

star0210 said...
Neither of us see any real value in getting a third opinion on these particular slides. The cost is completely a non issue. Another reading won’t change our coarse of action. .

Star, glad to see that you guys are open to radiation especially if the G8 is confirmed. Speaking of confirmed, have you reconsidered getting the slides read by Dr. Epstein? The difference between G6 and G8 absolutely COULD change your decision making...

Jim

JNF said...
I was on ADT for three years. There were inconveniences, but no real problems. After stopping The ADT I fully recovered from the side effects. The standard now is 12-24 months for high risk, so much less than I had. The ADT side effects go away for most all men. Surgical side effects after the initial healing are pretty much permanent.

Having surgery does mot mean he will not have ADT. If the surgery fails, which is very likely in high risk situations, then he will have salvage radiation which is often accompanied by ADT.

^^^^^^^ What he said. Very important ^^^^^^^

I just read through the visit notes.
This is what they said. (There are a few errors)

I spent greater than 45 minutes and consultation coordination of this patient's care.

Much of our Consultation regarded the discrepancy in grade of the carcinoma as assessed by outside pathologic report and our internal pathologist. Specifically, he presented as 3 cores with Gleason group 1 carcinoma no more than 5 mm in total volume and thus would appear to be a good candidate for continued active surveillance. However, review by M.D. Anderson pathologist reported on 8 August 2019 resulted in clinically significant upgrade of his left base biopsy sample to Gleason group 4 (4+4 = though in a less than 0.5 mm focus. We discussed the clinical impact that such a grading change has. I informed the patient that I have requested that our pathologists review this grading. I also informed the patient that I felt a repeat prostate biopsy was necessary prior to making a treatment decision as the isometer of a Gleason 8 carcinoma on a less than 0.5 mm focus can be difficult for the pathologist as they are looking at only a few glands with such a small focus of disease.

We then went on to discuss the use of MR imaging of the prostate to better localize disease within the prostate and better targeting of the biopsy. We discussed the picture distortion that the hemorrhage that is present within the prostate following a prostate biopsy can cause in the interpretation of images obtained to soon following prostate biopsy. I thus recommended that we wait an additional 3 months to allow the prostate to more fully heal before performing an MRI of the prostate. I feel that this delay in performing an MRI and repeat prostate biopsy will provide us better information without risk to the patient of a short delay should the Gleason 8 cancer be real.

We plan to bring the patient back in March for MRI and preoperative visit on the 16th and MRI/ultrasound image fusion guided biopsy of the prostate on 19 March.

a 51 y.o. healthy male with newly diagnosed prostate cancer secondary to abnormal PSA. Patient has been undergoing PSA screening since 2013, with values ranging between 2 and 3. Elevation to >4 with fPSA of 9% prompted prostate biopsy by his outside urologist. The DRE was reportedly normal. On biopsy, the outside pathology report notes only GG1 in 4 of 12 cores up to 40%. Internal MDA review has upgraded the small focus found in the LB to a GG4. The patient was previously counseled regarding his options based on the assumption that he had very low risk prostate cancer and was leaning towards AS.


51 y.o. male who presents with newly diagnosed prostate cancer, upgraded from very low risk to high risk based on re-read of biopsy specimens by MDA pathology. Since the treatment recommendations will vary markedly based on the Gleason score, we will ask for re-review by MDA pathology to confirm the findings of GG5 disease in the core from the LB. Due to the very small fragment of GG5 detected, we will recommend a repeat biopsy with MRI fusion to confirm the presence of clinically significant disease. In order to optimize the resolution & quality of MRI imaging, this will be obtained at 6 months from the prostate biopsy (March 2020).

Hubby and I discussed the situation tonight and while it won’t change our coarse of action, we have decided mainly out of curiosity (and frustration) to have the slides sent to JH for a third opinion (unless MDA gets back to us and say their upgrade was in error).
This discrepancy is just not sitting well.
Dr. Ward’s nurse replied to my message yesterday evening saying he would look into it and get back to me but hasn’t yet.

G8 is high risk. Send the slides to Epstein's lab; they are indeed the gold standard to conclusively evaluate biopsy slides. That number means a lot to the treatment plan. Any G8 is a G8, so you need to know if that G8 is really a G8. You have to know this, and trust that you do indeed know. You will have years to think, rethink, ponder, reflect, question, and wonder about everything you're doing at this moment. An assessment from Epstein's lab, for my money, is the only way you can have that confidence. If it is confirmed as a G8, there is no reason to wait for a treatment choice.

What do you get with another biopsy? You'll either get confirmation of the G8, or maybe even worse find some G9, or maybe only G6, or maybe nothing. If it's G8 or higher, your plan's the same as now. If it's G6 or nothing at all, well, you don't know anything new. That doesn't mean he doesn't have anything, or even that it's only G6. If you've found G8, then it is G8 and you already know it. Think of a biopsy as poking a lemon with a needle, and perhaps hitting a seed in there somewhere. Maybe he was lucky enough that they actually found the G8 in there, so he wasn't treated as only a G6. This could be good news, in a sense.

Mine was a G9, 5+4 case, and my PSA was only 5.2 at diagnosis even with multiple cores having 70-100% involvement. Even with that I had my slides double-checked by Epstein because that largely determined my course of treatment. I had radiation and ADT, and have been quite happy with the outcome.

All the best. This is one of the hardest parts of the whole process.

Not sure how I missed this thread earlier, but was just catching up on it and while reading it all I could think of "please get an opinion from Epstein" on the biopsy slides. As a result, I was so glad to get to the end and see that you're taking that step. Hopefully, that will give you some clarity on what you end up doing--right now the lack of clarity makes it so very difficult to make a decision.

Making a treatment decision was so very frustrating and stressful for me and ever day that went by I felt like I was wasting my time, so I can imagine what you're going through. Good luck to you and let us know what Epstein's lab says!

BTW, many people here have spoken on the phone with Epstein after the biopsy review. I would urge you to do that no matter what the result is since I think that info will be helpful for you.

Epic is the creator of MyChart and licenses it to hospitals and medical groups. One group's MyChart is not the same as the next groups although there are some provisions to access multiple MyChart accounts at login with some versions. If you have a login to the MDA MyChart system, you should be able to access items although it is not always clear where sometimes.

Hi Star. Much of the success of RP depends on whether the PCa is prostate-confined and, I would add, the genomics of the cancer. My PSA (correcting for finasteride) was about 8.6 when I got my G10 biopsy result. Since my RP more than 2 years ago, I have had no adjuvant or salvage therapy. Imaging can give you some idea about the extent of the cancer, but isn't a guarantee by any means.

The standard of care for high-grade disease after a RP with no major adverse features and an undetectable PSA is NO further treatment unless there is a PSA rise. about one-third of G 8-10 cases are prostate confined. Such results (mine included) can still encounter BCR, of course.

But you should of course consider all primary treatments including RT modalities.

Djin

This is absolutely outrageous!!
I cannot believe you are dealing with a world class institution.
It sounds like some incompetent hick place.
Almost every lab has no problem these days forwarding your slides wherever you want after you fill out the proper forms. Seems MD would work with you

Mel