Ever a Need for a 3rd Opinion on Bx?

Johns Hopkins changed Gleason Grade on 6 of 8 positive cores. Is this common for 2nd opinions, from board's experience?

Local Path Report...................Johns Hopkins 2nd Opinion Report
1......3+4 10%..........(down).....................3+3 50%
2......3+4 15%..........(down).....................3+3 80%
3......3+4 30%............(up)........................4+3 50%, Sets New Gleason Score G7
4......3+4 05%..........(down).....................3+3 20%
5......3+4 10%..........................................3+4 40%
6......3+4 30%..........................................3+4 04%
7-10...neg.................................................neg
11......3+3 10%.........(down)....................neg
12......3+5 ................(down)....................3+4 30%, Downgrades original G8

Or does it matter as far as treatment recommendations might go?

thanks

Setting aside how Epstein's review reflects on your first pathologist(s), the review puts you in the "Intermediate Unfavorable" risk category (Gleason Grade Group 3) and you need treatment. Whether or not you opt for surgery, keep in mind that a biopsy is only an estimate of what your Gleason score actually is (as would be determined by a post-RP path report). I say that not necessarily as a reason to opt for surgery, but just to point out that you actual status could be different from both slide reviews, e.g., G7 (3+4) with tertiary 5, if even a very small amount of pattern 5 is somewhere in your prostate. I see no reason for a third opinion on your biopsy.

As I may have mentioned in another thread, IMO, the key question now is to get an accurate estimate as possible via imaging as to whether your PCa is prostate-confined. PNI (perineural invasion), when seen at biopsy, statistically increases the likelihood of adverse path features from local growth out of the prostate. Was PNI also noted by Epstein? IMO, whether your PCa is prostate-confined is more important for your oncological outcome than your exact G score now that you have determined treatment is necessary.

Djin

JH noted PNI at Core 6, like the first report, but at the original Core 3 w/ PNI, have described it: "Suspicious for Extraprostatic Extension". Is that just a "Pre PNI"?

I am meeting at The Duke Multidisciplinary Clinic next week to get their "profit$ neutral" opinion on the best path forward on treatment, and will be ready to start/schedule in 10 days.

Manich, a staging decision is based on the highest/worst reading from the biopsy report. Either way, you've got at minimum a couple of 3+4's, or a 3+5 (which is kind of rare). Which makes you at the high end of intermediate risk--and both pathologists agree on that. It is doubtful that a 3rd read would downgrade you.

Which means, like it or not, that treatment is in your future. And, it will have to be fairly aggressive treatment, and fairly promptly. Which moves you from the pathologists to the oncologists. Best of luck at Duke--they are certainly among the best.

Guys, I know I am going to need treatment. But I, considering docs recommendations, have to decide what that treatment will be. I do not want surgery, and hopefully no more than 6 months of ADT. That is why I am trying to determine, as close as possible, the stage/group/progress of my PCa. In 10 days, after my Duke consultation, I should be well informed and ready to go.

Manich, whatever you decide will be the right decision for you. We all respect that. You are doing a good job of doing your due dilligence. To your question though, i dont see anything that could come up in a third opinion that would warrant a change in your treatment approach. As was stated by others, you've got an agreement on intermediate high risk (whether its 4+3 or 3+5, the latter which is doubtful from what i understand, i had 3+5 which was downgraded by Epstein, and a uro predicted that would happen saying that 3+5 is seldom used any more) prostate cancer.

FWIW, i was able to reach Dr Epstein with questions by simply calling him, i think i called at 7:30AM, and he picked up if i recall correctly. He was very generous with his time, and easy to talk to. So if you have questions relating to the reading, as i did, it would be worth your while to call him.

Good luck at Duke. You are approaching this in the best way possible.

Tudpock18 said...
.....you should be considering the non-surgical options of HDR-Brachy, SBRT and seeds + EBRT. If Duke does not have experts in all of these protocols please consider expanding your search until you get fully educated on all of your options so you can make the best decision possible.

So do either the HDR or LR seeds have to be removed? Or do either just weaken and stay in place? And do HDR seeds also combine with EBRT/IMRT,. My uro said that would probably be too hot. But what does he know, he was busy sharpening his knife as we talked. Jus' kidding. He is really a nice honest guy. But I know I need the RT, not a Uro, to get more informed on that.

Manich:

With LD brachy, the seeds go in and stay forever. With HD, they are inserted, and after a week or two (or longer?) they are removed. With SBRT, the put in gold markers that the SBRT focuses on for the radiation zap--I think they use gold because it captures the neutrons and then releases them over a period of a few days--which gives an extended radiation period.

Yes, talk to the RO's about Radiation and the different options.

manich said...
In 10 days, after my Duke consultation, I should be well informed and ready to go.

Excellent! Eliminate the critters! Every day a Pca cell dies is a good day!

I have to correct Hal regarding HDR. The single seed is attached to a wire and introduced into each of 15 catheters that are in the prostate. It may be in each catheter for a minute ow two or less depending on the amount of radiation desired in a specific spot. This is called dwell time. The whole radiation procedure takes about 15 minutes.

With HDR no seed or radiation is left in the patient. I asked my radiation oncologist what would happen if it were left in and he said within 3-5 days the patient would be exposed to enough radiation that terminal radiation sickness could set in.

Hal’s reference to two weeks is probably a misunderstanding. The common protocol currently, and what I followed, is that two HDR procedures are performed usually one week apart. But with each, the radioactive pellet/seed is only in the body for a total of 15 minutes and completely removed.

The HDR delivers an equivalent amount of radiation in 30 total minutes as permanent seeds deliver over 9 months or what external beam delivers over 25-30 fractions. The High Dose Rate means just that.

JNF said...
I have to correct Hal regarding HDR. The single seed is attached to a wire and introduced into each of 15 catheters that are in the prostate..................
.... The common protocol currently, and what I followed, is that two HDR procedures are performed usually one week apart. But with each, the radioactive pellet/seed is only in the body for a total of 15 minutes and completely removed.

Do they leave the catheters in-bedded, or are new catheters put in place the 2nd time?

JNF said...
The catheters are removed. Otherwise you would be bedridden as you can not move around, or walk or sit with them in..

Do they use the 1st treatment "puncture wounds", or do they implant in different areas. 20-30 catheter "wounds" seems like a lot of trauma to the perineum over a 2 week period.

Manich, the puncture holes have closed and started healing when the second procedure is performed. The catheters are about the diameter of the straws that come attached to a juice box drink. They are about a foot long and are closed and sharply pointed on the end that punctures the body. They actually do the initial puncture with a stainless steel rod that looks like an ice pick. I never asked if the same holes were used. The catheters are placed through a template that is sewn on the perineum area to be a stable platform for placing and inserting the catheters. After the radiation procedure, the stitches with the template are cut free and the template and all catheters are pulled out in one quick action. As a I was still numb from the spinal block I felt nothing.

There is some trauma to the area, but no incisions are made so the damage is very minimal. The day of the procedure they put a pad in my underwear and that evening when I removed it there were some small blood spots, but nothing after that. For a few days, the area is tender and you have to be careful to choose soft chairs and not to plop down onto a seat, but rather be ginger about it. Absolutely no problem after the third day or so. I did not change any activities other than being careful sitting down for a few days.

One side effect that no one informed me of was rather interesting. Since there is some bleeding from the catheter insertion and it follows gravity my junk was nearly black from the internal blood when I woke up the next morning. It was not a problem and was not painful, but it sure was weird. about a year later I was helping a client (also a good friend) prepare for brachytherapy. I was explaining the process and side effects and explained that my junk turned black for a week or so. To that he just laughed and said “no problem for me”.......suddenly I was embarrassed as he is African-American with a wonderful sense of humor. We had a good laugh and he made sure he reminded me of it when he had the procedures done.