Two Clinical BX reports from different LABs ?

Hello
I had a recent bx Dec 9th 2019.
Bone and CT scans Dec 30th, 2019
The insurance company made the Uro sent initial biopsy to independent lab DIANON.
DRE - hardness of right side
PSA 2.2
Bone scan : negative abdominal and pelvic regions ( bright spot on right rib) getting an MRI of right side.
CT Scan: found infernal abdominal aortic aneurysm . polyp in colon. Referred to others for colonoscopy
and vascular surgeon diagnosis abdominal aortic aneurysm.


The initial clinical report indicates:
Left base, Right Base, Right Base #2 3+4 Grade 4 comprises 10% of tumor (2%, 20%, and 25% of total bx lengths respectively)
Left Middle 3+4 Grade 4 comprises 20% of tumor 10% total biopsy length)
Left Apex and Right Apex - Benign
Right Mid, Left Mid 3+3 (1% ,10% of total bx lengths respectively)
Left Base #2 3+4 (Grade 4 comprises 20% of tumor 10% total biopsy length)
Left Apex #2 High Grade PIN
Right Mid #2 3+4(Grade 4 comprises 40% of tumor 20% total biopsy length) 4mm
Right Apex #2 3+4 (Gleason Grade 4 comprises 20% of tumor PIN high grade 11% total biopsy) (2mm)

The 2nd clinical path report was by an oncologist in my Uro Group who is in a QA program with John Hopkins and my Uro claimed he has never been overturned by Dr Epstein @ JH. I hope that is the case because it show 3+3 in 8 cores and only 1 core 3+4.

Here are the second opinion diagnosis results:
LB : Gleason 6 3% of specimen involved. Ends not involved by the tumor.
LM : Gleason 6 10% of specimen involved. Ends not involved by the tumor.
LApex: Benign
RBase: Gleason 6 20% of specimen involved. Ends not involved by the tumor.
RM : Gleason 6 3% of specimen involved. Ends not involved by the tumor.
R Apex: Benign
LB #2 : Gleason 6 20% of specimen involved. Ends not involved by the tumor.
LM #2 : Gleason 6 10% of specimen involved. Ends not involved by the tumor.
L Apex #2 : HG PIN
RB #2 : Gleason 6 20% of specimen involved. Ends not involved by the tumor.
RM # 2 : Gleason 7 3+4 20% of specimen involved. Ends not involved by the tumor. Gleason 4 10% of specimen
R Apex #2 : 10% of specimen involved. Ends not involved by the tumor.


I had my slides sent to Dr. Epstein @ John Hopkins per the advise of others in this forum.
My question is Is it safe to assume that the 3rd path report from Dr Epsteins group should be the one I make my treatment decisions or should I compare / combine the results with the 1st two path reports somehow? The two reports seem so different I don't know what to think. Hoping the 2nd opinion is the accurate diagnosis for obvious reasons.

I would appreciate any advise on path reports or best treatments based on current info.

Regards,
Newbie2pc

Yes, Dr. Epstein is the top guru. However, active surveillance (AS) will be off the table. Even if all cores were to come back G6, the number of positive cores throughout the prostate makes AS inadvisable. While you won't know for sure about your biopsy until then, IMO, the odds are there will be some pattern 4. I wouldn't think your treatment choice will differ based on a biopsy of G6 (3+3) vs. G7 (3+4) if the cancer appears to be prostate-confined (the Gleason score of a biopsy is that of the highest-grade lesion).

The imaging you had may be enough to get an idea whether the cancer is prostate-confined. The MRI should tell you and your doc more about the rib lesion. In the meantime, chill out! You can read up on the common primary-treatment decision, surgery vs. radiation. With the latter there are different modalities and combinations to consider.

I would start a notebook or pad with your questions for your doc and/or the Forum. As they are answered, you'll have more

A diagnosis of prostate cancer is always a shock, but this is a long game. Relax and welcome! Keep us updated, please.

Djin

What the benefits of 3t mri ? My uro stated he was not a big fan of that test? My understanding is it is better for guiding biopsy and is not a randomized biopsy. Can it show if tumor is extruded outside of prostate or lymph node involvement etc...?

A (3T) mpMRI can identify suspicious areas in the prostate and assign each a 1 to 5 PIRADS where 1-2 are likely not cancer, 4-5 are, and 3 is intermediate. The image can be "fused" with the ultrasound image your doc uses during the biopsy to guide the need to those areas. The takeaway messages I've gotten from studies are:

1. PIRADS 4 and 5 targets warrant a biopsy, but its prudent to biopsy when the highest target is a 3. PIRADS score are not diagnostic of cancer -- even a 5 lesion can turn out not to be cancer.

2. The biopsy should not be limited to cores only in the identified targets, but should include the standard "random" cores in all prostate zones, with extra cores in the identified targets. I have seen Forum brothers where the MRI targets turned out not to be cancer, but the biopsy found cancer in non-target areas! When PCa is strongly suspected, many uros will want to do the biopsy even if the MRI is negative.

Both an MRI and a biopsy can miss existing PCa lesions, but the combination is statistically better than a biopsy alone. Only a biopsy can actually diagnose PCa. My uro isn't a big fan of MRIs also, but says they have their use.

Djin

Post Edited (DjinTonic) : 1/8/2020 8:35:24 AM (GMT-7)

Newbie2pc said...



I had my slides sent to Dr. Epstein @ John Hopkins per the advise of others in this forum.
My question is Is it safe to assume that the 3rd path report from Dr Epsteins group should be the one I make my treatment decisions
Newbie2pc

Yes, use Dr. Epstein's report.. But unless a lot of the G6's go away you are still likely headed for treatment. The good news is that you will have a lot of choices...that's also the bad news.

Jim

Newbie2pc said...
What is number of positive 3+3 cores is the cutoff for AS?

Different place seem to have different guidelines, 2,3,4? Then if they all have less than 50% involvement, that's good. Over 50% in any core then AS probably not likely. Even in my case, I had 2 bx's. 3 positive the first time, 4 positive the second time. Neither of the two uro's I've consulted with are counting them as 7 and seem to consider them 2 separate events.. I had 2 pretty good MRI's and a pretty good genomics, OncotypeDX, score going for me.

This is interesting and gave me a headache. I remember the 33% of total cores cutoff from the AUA 2017 or 2018 Report that my urology surgeon Dr. Martin Sanda was part of. I'm also enrolled in the Canary PASS program through him which also seems a tad more lenient. Not sure if I feel any better but this is a helpful link. Thanks.