Help with Interpretation of Biopsy Results

Hi Taylor. It's a Gleason score of 6 (3+3). Two of the 12 cores were positive (G6), one on each side. In addition, both positive cores had a very small percentage of malignant vs healthy tissue. Your lesions are the common acinar adenocarcinoma type rather than any rarer, usually more serious, kind of tumor. From what can be judged by a biopsy, there is no evidence of spread outside the prostate.

They are using a report template, which is why the "Percentage of Pattern 4 in Gleason Score 3+4=7 Cancer:" item is there, but marked "Not Applicable."

You doc may tell you that you are a candidate for active surveillance (AS), provided you adhere to a protocol. However, looking at your other thread, your PSA was just over 10. Some AS protocols require an entry PSA below 10.

AS protocols usually require a confirmatory biopsy at some point. The reason some men in AS programs are told at some point they should seek treatment are at least four: (1) their PCa has progressed and lesions >G6 have been identified, (2) the tumor burden (amount of G6 disease -- number and/or size of lesions) has become too large to presume there are no higher-grade lesions being harbored, (3) their G6 disease (which itself cannot metastasize) has grown locally out of the prostate, or (4) their PSA has risen too high (usually >10) and metastasis has to be considered). Men on AS are followed by PSA, DRE, imaging, and biopsies.

The fundamental problem with a G6 biopsy is that you cannot be certain there aren't currently also lesions greater than Gleason 6 (roughly one-third of G6 men who opt for prostatectomy are upgraded, meaning leasions >6 are found when the whole prostate is examined). Only repeat investigations when on AS can give you a window into the likelihood that your PCa has progressed and that you need to seek treatment.

Let us know how the discussion about your results goes with your uro, please. I do think your high PSA is of concern and a mpMRI may be in order, and, depending on the results, a repeat (targeted + systematic) biopsy as well.

Djin

While, as others have noted, it is right to keep a close eye on things given the PSA, I've been on AS for several years and my PSA are risen to around 12. My docs are not worried because my prostate was about 150 ccs, which is very large and the PSA assessment has to be adjusted for that. In addition, I've had several MRIs, all negative. Also, while AS programs usually have biopsies every 2 years, when my PSA rose above 10, I had a biopsy one year after the last one. So AS is very much a possibility for someone with so little G6 cancer, but do make sure you've got a very experienced doctor with a very active AS program.

As someone who had a long history of BPH with a slowly rising PSA, I can tell you that those with BPH have to be careful. Men with BPH have a slightly lower incidence of PCa (for reasons still not fully understood but conjectured to be related tothe increased physical pressure on individual cells cased by the excess growth). Nonetheless, these men have to be carefully monitored because an PSA increase larger than expected should raise suspicion for cancer (I had 9 negative biopsies over the years until a last, positive, one).

On a separate note, I strongly suggest that any G6 fellow contemplating AS have his prostate tissue sent for a genomics test such as Decipher Biopsy or OncotypeDx to learn their 5-year risk for metastases. A seminal Decipher study showed that 10% of men with G6 PCa (as confirmed by post-RP pathology), are high risk for metastases when their biopsy tissue was tested. Although it is true that G6 itself can not metastasize, these men are high risk for forming lesions >G6 which then metastasize). If I were an otherwise good candidate for AS, but resulted high-risk for mets I would choose treatment over AS. A very small number of men fall through the cracks of AS programs: while most of the men who leave AS for protocol reasons have successful treatment outcomes, a very few have metastases by the time their disease progression is noted. I would presume these men could have been screened from AS by genomic testing.

Djin

I would only add that sending the biopsy slides to Dr. Epstein at Johns Hopkins is never a bad idea. Most insurance plans cover it (I think), but even if not it's $275 (last time I did it anyway) well spent. Very easy to do.

http://pathology.jhu.edu/department/services/secondopinion.cfm

Regarding bilateral prostate cancer, I would point out that for PCa confined completely to the prostate, the laterality of lesions (uni- to strongly bilateral) is irrelevant. The current (8th) edition of the TNM staging guide did away with the a, b, and c subdivision of the pT2 (prostate-confined) stage. The pT2c path staging I got after my RP back in 2017 would today be reported as simply pT2. I have seen at least 3 studies supporting this staging decision published since the 8th edition was adopted: the location of PCa lesions in prostate-confined disease has no correlation with oncological outcomes. This is in contrast to the total amount of tumor present (usually reported as % prostate involvement after a RP), for which there does appear to be a inverse correlation with good outcomes in prostate-confined cases.

For various reasons I chose RP over RT for my primary treatment; however, I if I were making a choice amoung RT options, I would look into SBRT, which appears to have better outcomes than brachy. You have valid reasons for not being interested in AS.

It's prudent to get a 2nd opinion on your biopsy slides from Dr. J. Epstein at Johns Hopkins.

Djin

Post Edited (DjinTonic) : 3/10/2021 1:57:38 PM (GMT-7)

Not sure why you did not NOT put all your information that was pertinent to your situation in your first post...actually I do have a good sense of why...but it is water under the bridge...sorry...I am just saying what others are thinking,,,it is my specialty... just treat it....radiation would be my advice...but what would I know I just play a doctor on tv and cancer forums...ignore all above at your discretion...which means not shouting what you are ignoring...hence not ignoring it... to the roof tops... again apology for my pov...regards logo

My apologies everyone for my original post omitting all of my cancer journey.

Been a stressful day and I was in a hurry to get help with interpreting the pathology results

Taylor, not much to add except to say that you're asking the right questions. Your history is certainly important as well, the neuroendocrine history needs to be a part of the whole picture when it comes to the treatment decisions.

Hang in there--the answers will come.

Good to hear from you Cyclone. Thanks again for your kind, supportive words.

I received a phone call from my Urologist to discuss my new cancer diagnosis. Proceeding with bone scan and CT scan and once have those results we are going to schedule cyberknife radiation. Due to my age; he is not wanting to take an AS approach. I feel much better now that I somewhat have a tentative game plan.

Again, I really do appreciate you taking the time to reach out.

Thank you Halbert. Appreciate the positive message

Djin Tonic,
The removal of the T2 cathegories is true but it applies to path reports. Technically, any positive biopsy triggered by psa screening, without a prevoius bilateral DRE finding (not sure about about image verification, because I think it has also changed) is always considered T1c. T2a correponds to a previous one side DRE finding, etc. It does not have to do with the location of the biopsy cores. I guess this is still mantained.
My comment was not on the technical point of staging (difficult to precise in a biopsy anyway) but about the bilateral finding that implies a multifocal or large volume tumor. This may not be so much relevant for prognosis as it was believed to be, but its is important to decide if AS is an adequate option.

Taylor, you are getting a lot of useful information. Thankfully your dx is at the present very low risk and not in need of invasive treatment.

If you are to treat currently, I highly recommend either High Dose Rate Brachytherapy or SBRT external beam. The HDR-BT could be done as mono-therapy and likely in one fraction, two at most. I used HDR-BT 10 years ago and have done well. Either of these would be superior to permanent seeds brachytherapy or traditional external beam low fractionated radiotherapy.

If you are to use AS, I would certainly find out why the PSA is 10 with such a small amount of cancer. What is the estimated prostate size? Have you had or been treated for BPH or prostatitis? What prompted the biopsy?