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Posted 2/4/2020 2:46 PM (GMT 0)
I got my pathology report back, G8, and asked my doc about getting a 2nd opinion. He said we need to wait until imaging is done, and those results are returned. He said if I am the rare case of metastasis, I've been having the symptoms, with my "low" PSA of 11, that treatment will be planned around the mets, and not any change in my biopsy grade. Should I wait for imaging results, they still haven't called to schedule them, or push to get my slides sent to JH for a 2nd opinion? If JH downgrades my 3+5 to a 3+4, I would drop from a Group IV to Group II. That seems like a big change, and a "much nicer landing spot"!
Posted 2/4/2020 2:56 PM (GMT 0)
My two cents.
Have the imaging done.
Then send both the images and biopsy slides sent to JH.
Always best to have a second opinion.
Posted 2/4/2020 3:21 PM (GMT 0)

alephnull said...
My two cents.
Have the imaging done.
Then send both the images and biopsy slides sent to JH.
Always best to have a second opinion.

I wasn’t aware that JH does 2nd opinions on imaging also.
Posted 2/4/2020 4:07 PM (GMT 0)
Well, I just assumed they would. I'd check, but to give you a better evaluation I would think they would.

When I had my 2nd opinion done with MDA, imaging, surgical report and biopsy were all sent.
Posted 2/4/2020 4:59 PM (GMT 0)
I see zero downside to getting the second opinion on the biopsy now. More knowledge and having it sooner beats...well, I think it beats about everything.

Also: 3+5 is an atypical reading. (I believe one of our regulars might have that initial diagnosis. Maybe Pratoman?) I think you want to get that sorted out.
Posted 2/4/2020 6:06 PM (GMT 0)
Hi manich. By all means get a 2nd opinion from JH at some point before treatment. Knowledge is good. If you opt for radiation, the biopsy report(s) will be the final word on your Gleason score.

One study found for 25,000 cases of G8, (3+5) accounted for about 10% and (5+3) for about 3.5%. From your data it's clear that the pathologist(s) judged your cancer to be heterogeneous -- lesions with different G scores. You can do you own searches -- but studies I've seen found long-term outcomes of G8s with pattern 5 are somewhat worse than (4+4)-- just how much depends on the study. G8 (5+3), in fact, has been equated in risk to a G9 (4+5). Another pathologist might find your amount of pattern 5 is less than the 19% in your report-- so you could be downgraded to a G7, (3+4) or (4+3), plus a "tertiary 5" -- which many pathologists use to report a third pattern when it accounts for <5% of the total. (A biopsy Gleason score is always that of the worst lesion; however, men having RP often find their overall, final G score is up- or downgraded when much more of the prostate is examined.)

However, this is all, in one sense, just a numbers game -- The main points, IMO, are that there is pattern 5 (to be confirmed), your is PSA > 10, and your PCa needs to be taken seriously.

Once it's recognized that PCa requires treatment, the next question in estimating whether it is prostate confined -- part of the purpose of your upcoming imaging. This is what your doc is focused on, I gather. If your PCa is confined within the prostate capsule, a very good long-term outcome is certainly possible. The presence of PNI (perineural invasion) seen at biopsy does mean a higher risk of adverse features being present when the whole prostate is examined (if you choose RP as your treatment). If there is local growth outside the prostate, but no mets, the treatment outcome can still be good (the treatment might still "get" all the cancer), but the risks of BCR (a return of a rising PSA) become greater.

Keep us posted,

Djin
Posted 2/4/2020 7:22 PM (GMT 0)
Waiting for the imaging seems okay. Still, I don't think you need to wait for that to send the slides out.

The is right though, with mets the game is different than without mets.
Posted 2/5/2020 12:17 AM (GMT 0)
If the imaging confirms mets, (small chance?) then a second opinion won’t matter. If there are no mets, then a second opinion could matter a lot, and could be instrumental in informing treatment.
With that said, I agree with Michael T. There is no downside to getting a 2nd opinion from EPSTEIN, other than the cost ($275?)

Also, manich, Michael is correct, my biopsy showed g8(3+5). A well known surgeon (not the one I ultimately hired), commented that 3+5 is not even used any longer and that EPSTEIN would surely render a second opinion that’s different (this was in late 2014). I’m not sure what he meant by “not used anymore”.

In any case, Epstein’s second opinion called it a G6. That was ultimately confirmed by MSKCC, then my surgical pathology turned out to be G7(3+4).
Getting a 2nd opinion now will save you time, should the imaging show no mets, and might ultimately prove very useful
Posted 2/5/2020 12:28 AM (GMT 0)

Pratoman said...
..
Also, manich, Michael is correct, my biopsy showed g8(3+5). A well known surgeon (not the one I ultimately hired), commented that 3+5 is not even used any longer and that EPSTEIN would surely render a second opinion that’s different (this was in late 2014). I’m not sure what he meant by “not used anymore”.
...

Gleason score 5 + 3 = 8 (grade group 4) prostate cancer – a rare occurrence with contemporary grading [2020]

"Summary
Grade Group (GG) 4 prostate cancer includes Gleason scores (GS) 3 + 5 = 8, 4 + 4 = 8, and 5 + 3 = 8. Some studies without pathology re-review of historical cohorts proposed that the presence of pattern 5 worsens prognosis compared to GS 4 + 4 = 8 cancer. We assessed how often historically graded GS 5 + 3 = 8 cancers retain this grade with contemporary grading recommendations. Sixteen prostate biopsies and 24 radical prostatectomies (RP) reported from 2005 to 2019 as GS 5 + 3 = 8 were re-reviewed and graded according to contemporary recommendations. In discrepant cases, an attempt was made to explain the different grading. One (6%) biopsy and 3 (12%) RPs remained GS 5 + 3 = 8 (GG4) after re-review. Two (12%) biopsies remained GG4 but were re-graded as GS 3 + 5 = 8 and 1 (4%) RP was reclassified as GS 4 + 4 = 8 (GG4). Eight (50%) biopsies and 15 (64%) RPs were upgraded to Gleason scores 9–10 (GG5). Five (32%) biopsies and 1 (4%) RPs were downgraded to Gleason score 7 (GG2 and 3). One (4%) RP showed GS 3 + 3 = 6 (GG1) cancer. Data from 2013-current from the three institutions were available to assess the incidence of GS 5 + 3 = 8 following re-review of the cases. Out of 14 359 biopsies with cancer and 6727 radical prostatectomy specimens, only 1 case (0.007%) and no cases (0%) were graded as GS 5 + 3 = 8, respectively. Reasons for grading discrepancies included: 1) assigning an overall common grade to separate needle cores or tumor nodules; 2) inclusion of <5% lower grade pattern into grading; and 3) misinterpretation of variant histology and patterns. Challenging patterns were poorly-formed glands, signet ring cell-like features, atrophic carcinoma, ductal carcinoma, and mucinous fibroplasia. GS 5 + 3 = 8 (GG4) cancer is very rare with contemporary grading. The reliability of conclusions from retrospective databases regarding the clinical significance of this grade combination without slide re-review is questionable."

[Emphasis mine]

I don't know how uncommon G8 (3 + 5) has become, but we know G7 + tertiary 5 isn't rare, and the OP has pattern 4 present. It would be instructive to see a review by Dr. Epstein.

To Pratoman's point, imaging might not be conclusive, if, e.g., the bone scan is negative and CT shows one or two slightly enlarged local nodes.

Djin

Post Edited (DjinTonic) : 2/4/2020 6:09:31 PM (GMT-7)

Posted 2/5/2020 2:30 PM (GMT 0)

DjinTonic said...


However, this is all, in one sense, just a numbers game -- The main points, IMO, are that there is pattern 5 (to be confirmed), your is PSA > 10, and your PCa needs to be taken seriously.


How much weight does the PSA carry in treatment options/plan? My symptoms seem to grow by the day, and I would bet my Dec PSA of 11 could be a lot higher by the time I, and my doc, get to the point of deciding on a path forward. Is it common to get another "pre-treatment PSA baseline" on record to refer to as treatment begins?
Posted 2/5/2020 2:51 PM (GMT 0)

manich said...

How much weight does the PSA carry in treatment options/plan? My symptoms seem to grow by the day, and I would bet my Dec PSA of 11 could be a lot higher by the time I, and my doc, get to the point of deciding on a path forward. Is it common to get another "pre-treatment PSA baseline" on record to refer to as treatment begins?

First, I am not a doctor! While the >10 or <10 figures into some nomograms predicting outcomes, as you mention, your PSA is behind your doc wanting to know if you have any current mets. I would hold onto your question until you get your imaging results (bone scan and CTs w and w/o contrast). Then you can discuss the ADT question when you go for your consultations. In other words, I believe prostate-confinement is a more important issue. Tumors vary in the amounts of PSA they produce per gram of malignant tissue -- they certainly don't read lab reports smile

The question of ADT and when to introduce it plays a big role in RT. ADT before surgery has also been looked at.

Neoadjuvant Androgen Deprivation Therapy Prior to Radical Prostatectomy: Recent Trends in Utilization and Association with Postoperative Surgical Margin Status

"CONCLUSIONS:
After a period of steady decline, there appears to be a modest trend towards increased utilization of neoadjuvant ADT in more recent years. We found an association between neoadjuvant ADT and decreased odds of positive surgical margins among low- and intermediate-risk patients."

Post Edited (DjinTonic) : 2/5/2020 7:55:52 AM (GMT-7)

Posted 2/5/2020 6:31 PM (GMT 0)
...and back to your original question...my two cents would be to go ahead and request the second pathology opinion from Epstein now. I don't see the downside of having that added knowledge in hand. Also, am I reading your signature correctly and that you have had a 6+ PSA since 2008? If so I'm curious why someone suggested you wait until 2020 before getting a biopsy.

Jim
Posted 2/5/2020 8:48 PM (GMT 0)

Tudpock18 said...
Also, am I reading your signature correctly and that you have had a 6+ PSA since 2008? If so I'm curious why someone suggested you wait until 2020 before getting a biopsy.

Jim


"Inactive Surveillance" from 2008 thru 2017, steady at 6. In 2018 MDx test came back with 13% chance of high risk PC. I "gambled and lost".
Posted 2/6/2020 1:58 PM (GMT 0)
Generally the higher grade PCa expresses less PSA by volume of the cancer. So a PSA of 11 and G7 or 8 would typically indicate a much greater tumor load volume than a G6.

Is there a real difference between a 3+5 and a 3+4? Perhaps, perhaps not. Depends on the volume by percentage and the genetic makeup. It may be a distinction without a difference when it comes to the risk you face and the treatment that is best. PCa is far more complex than just G grades/scores and tumor volume. There are 24 variants that have been recognized and it is possible that some types of G4 are worse than some types of G5. That you know you have at least G4 working means the real potential of active treatment, hopefully curative.

And I wouldn’t be dismissive of a “low” PSA of 11. That is about double what it has been so something is clearly at work causing the rather fast increase. I think it is time to get better information and formulate a treatment plan. The cancer will not take a breather as you investigate and decide. I would at least have Epstein’s opinion in my pocket while pursuing the scans. Why add several weeks to the process and stress it creates?
Posted 2/6/2020 5:10 PM (GMT 0)
How long does it usually take to get results from JHU after start with the process with them of seeking a second opinion? [i'm sorry if this is mentioned elsewhere--just occurred to me after reading JNF's post]
Posted 2/6/2020 5:33 PM (GMT 0)
FreeWill88, I have heard it usually takes 2-3 weeks to get slides read and get the results. Some of that is administrative time by the sending firm and then the mail and shipping time. I imagine the time at JH is minimal.
Posted 2/6/2020 5:53 PM (GMT 0)
Thanks JNF
Posted 2/6/2020 7:32 PM (GMT 0)

JNF said...

I wouldn’t be dismissive of a “low” PSA of 11. That is about double what it has been so something is clearly at work causing the rather fast increase. I think it is time to get better information and formulate a treatment plan. The cancer will not take a breather as you investigate and decide. I would at least have Epstein’s opinion in my pocket while pursuing the scans. Why add several weeks to the process and stress it creates?


My comment on my "low" PSA 11 was in reference to having it already metastasized. I have had 2 uros tell me psa would be much higher if it had gone to mets.

My uro said he wanted to wait for my scan's(on 2-13) coming back to him on 2-17, before sending slides to JH. But I have scheduled a consult at the Duke Cancer Center's Multidisciplinary Clinic for New PC Patients on 2-28, and asked my uro to PLEASE send my slides to JH now, so I would get them back in time for the Duke clinic. He agreed.
Posted 2/6/2020 8:51 PM (GMT 0)
I don’t disagree that when a dx includes Mets the PSA is usually higher. But for most men diagnosed with high PSA and Mets it is usually their first PSA test, or first after a long time between tests. That you have a consistent test history one should expect to find Mets sooner and at a lower PSA than one with no testing history. Of course with a long testing history you are more likely to find disease that needs to be treated before Mets become apparent.

Are the docs looking for Mets (distant) or locally advanced disease? For example, capsular escape and seminal vesicles invasion are not judged to be Mets, but could indicate reduced effectiveness of surgery as treatment and requiring radiation and often ADT as initial treatment. If distant Mets are found some doctors rule out any local treatment to the prostate and go straight to systemic treatments like ADT and cytotoxic chemotherapy.
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