MRI & Biopsy results

I had the MRI overlay biopsy last week and Doc called with the results today. One of the two areas of greatest concern (anterior side of prostate) showed cancer and one of the 12 random cores showed cancer. Doc scored it Gleason 8 (if I understand this correctly the "8" is a combination of two scores but he did not give me that info, just said Gleason 8) but added that this is not something to "wait and see". Getting scheduled for abdominal CT Scan and a whole body bone scan. (Doc expressed his opinion that he expects those to be "clear".)

I started this journey almost 4 years ago with rising PSA results. Had a TR biopsy and was given the "all clear" sign. Big relief. Thought I had skated on this one. But the occasional blood in my semen continued off and on and become more and more common. Changed docs and hospitals (now at St Luke's in St Louis County for those acquainted with the area) to get "second opinion" and it is Gleason 8. A bit pissed off that my original doc did not pursue the MRI many months (or years) ago. In fact, if biopsy results yield false negatives 35% of the time, they kind of meaningless. At least it was in my case.

I assume the two new tests scheduled will better determine if the cancer has already spread beyond just the prostate. It's been almost 4 years since I got my PC 101 education by reading here and I realize I'm going to have to start that all over again to refresh my failing memory. I'm going to print out the OP with all the questions I need to be familiar with when I actually sit down with the doc.

If you're really bored and want to start at the beginning you can click on my name/ID and see my earlier posts.

If you have an suggestions on specific questions I need to ask during the sit down, please do not hesitate to reach out.

It's not one core: it's one of the RANDOM (12) cores PLUS a hit on one of the TWO areas of concern. Agree that the scans are unlikely to show much (so try not to lose too much sleep) but you do need some sort of treatment. PSA nice and low, which is probably a good thing.

Many questions to ask but ones I would put high up the list (in the radiation v surgery decision) are: where is the cancer relative to nerves and what are my prospects for continence difficulty after surgery? On the same decision, a question for you is do you have urinary symptoms? My prior would be you should get radiation but as a surgery guy, happy to suggest to you what to look out for.

Make certain you get a complete copy of your biopsy report and not a summary. It's an important document. It's a good idea to have all your biopsy slides reviewed by Dr. J. Epstein at Johns Hopkins. Your doc can have them sent directly at your request: this is a common practice and it's not unusual to have one's biopsy up- or downgraded. Please add the salient features of your biopsy to your signature. You'll want to know if the Gleason 8 was a 4+4 or a less common 5+3 or 3+5. The prevalent Gleason grade (also called pattern) is listed first in Gleason score and the second-most common grade is listed second. A biopsy (overall) score is that of the highest scoring lesion.

Start a list of questions to ask your doc and those you consult with. Read up on treatments and ask questions here as you like.
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There is a misconception about the implications of biopsies missing existing PCa. The fact is that it is unlikely that cancer can escape repeated biopsies. Assume a biopsy will miss cancer one-third of the time and do the math. If you take men with existing cancer who have, say, from one to three biopsies over a period of a few years, less than 3% (1/3 x 1/3 x 1/3) should go undiagnosed. And that ignores the role that imaging like MRI now plays in locating lesions.

All the best,

Djin

I updated my signature to only the newer results. I had not included that the most recent PSA was while on FINESTERIDE which was 4.7 and Doc says the med artificially reduces the PSA by 50%. Thus PSA was considered to be 9.4.

Scheduling appt today for review with Doc and to set CT Scan and bone scan. Like most of you, Doc was very optimistic that scans would be "clear". (But then so was my first biopsy result.)

I see that I really need to do a lot of reading again to educate myself. Four years ago I felt that stumbling upon this group was the best thing that could have happened. The knowledgeable contributors here and their experiences are unmatched anywhere I know. When I got that "all clear" biopsy result (04/2019) I felt kinda bad of all the fretting I did and felt I probably took time from others that really had serious issues. Guess I've "graduated" to having "serious issues" and at least I'm not starting at Ground Zero on educating myself here.

I will update when I learn the actual Gleason scores. My current line of thinking is that if this is truly confined to only my prostate then getting the darn thing cut outta there seems to be the way to go to ensure a longer life. I am at least somewhat aware of side effects. My urinary incontinence is not "terrible" at the moment, other than I only get that 2-minute warning (which is OK at home with 5 BRs but can be a problem out and about) and I wear a light pad for "dribbles". But I guess I'm likely to lose the "romance" that I currently still am capable of. Not saying it's like I'm 35 anymore, but it's OK for being 66yo. Some of the meds I'm taking have already had some unfortunate effects on that department.

I have 5 friends that have had PCa who are the kind of friends you can discuss this with in some detail.
One is an internist - 55yo- (never my doc, just travel companions) who immediately on diagnosis elected to have RALP (hope I got that right -- robotic surgery). He lost all bedroom action and lost total control of urine and eventually received an AUS. No further complications after 5-6 years. He's a doc. Surely elected the best surgeon in his opinion but guess he still lost all those nerves. NOT great SE to have. But, he's alive.

#2 is a Postal Worker - 56 yo - who drives all day. Also had RALP. No urinary issues. Says he can kinda perform in the bedroom. It's been 8 or more years with no additional problems.

#3 is a contractor friend -- guessing about 55 yo -- who quite recently had RALP at St Lukes's (St Louis) and claims it all "still works". (His wife confirmed that with my wife.) which is one reason why I elected to go to St Lukes and see his doc if I do decide on the surgical route. The other reason is I could get the earliest appt. Still intend to have a consult at Siteman (Barnes).

I do not know anyone who went any other route than surgery. Your input greatly appreciate.

Cribriform and intraductal morphology are serious factors, and confirm that you have a high risk case.

You may want to consider a triple play of beam radiation, a brachytherapy boost, and ADT to maximize your odds of a curative treatment.

https://www.medpagetoday.com/hematologyoncology/prostatecancer/71560

I agree with ASAdvocate -- among the things to discuss with your doc is the presence of "cribriform pattern 4". It is a significant report finding. You might ask whether this finding effectively bumps you up one group to the equivalent of Gleason Grade Group 5. This is another reason to ask for a slide review from Dr. Epstein at Johns Hopkins.
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@ShawsUnprostatedMan I don't think so and it was my uro/surgeon who brought this up. Coupled with other factors, my repeat negative biopsies were one factor that led me to believe my cancer had not been around a great length of time and helped me decide for surgery. My last biopsy was prompted mainly by the finding of a nodule on DRE. The nodule was sampled in the biopsy and turned out to be negative--the 2 out of 14 positive cores were at the opposite end of my prostate. (Out of curiosity I asked my surgeon at a visit not too long ago about the negative nodule and what the chances were that all cores in that zone simply missed the nodule. He said "zero" without hesitation.)

A commonly overlooked fact is that a "random core" is often not random: the uro is using the ultrasound screen to target any "suspicious" area in each zone. Abnormal tissue loses density and reflects less energy than healthy tissue. Of course there is no way of knowing whether or not abnormal tissue is cancer during the biopsy, and much depends on the doc's experience.Could the last few of my negative biopsies have missed my cancer—it's certainly possible. However, putting all of the indications together, I believe my good result (so far) after a G10 biopsy can be attributed mainly to early diagnosis: finasteride-corrected PSA below 10; my TURP pathology was negative for PCa; pT2 R0 N0 final path with no enlarged nodes on imaging; total estimated tumor burden of just 5%; and a post-op PSA nadir of 0.007; having had uro checkup every 6 months after my TURP; plus my many previous negative biopsies.

A quick, very rough estimate using just 12 cores of my final biopsy (since the extra cores were for the nodule, which was benign) and a 5% tumor burden (confirmed to be bilateral after surgery): Each "random" core had a 95% chance of missing cancer, so 0.95^12 ≈ 0.54 or a 46% chance of at least one core being positive. In fact, my uro found lesions in two different zones, which IMO is pretty good for a relatively small amount of cancer, whether you go by chance alone or factor in uro skill and experience with the ultrasound screen.

But to your question, yes a 1/3 chance of a single biopsy missing cancer is indeed significant, which is why uros who strongly suspect PCa after a first negative biopsy, usually want a repeat after some time interval, especially if the PSA keeps rising. My point is that it's unlikely PCa can go undetected for very long with repeat biopsies.

ADT was mentioned by someone specifically and is part of the treatment plan of many men here.

I have been on TRT (Testosterone Replacement Therapy) for over 20 years and currently take weekly injections. No doc has blinked an eye at this though it's clearly in my medical record and on my Rx list.

Should I discontinue this?

Thanks Mumbo, I think I just edited out the duplication a few minutes ago. It was a "cut and paste" directly from the report because as for now, I don't know what is necessary to include and what I could exclude.

It seems logical (to me) to discontinue TRT; I am puzzled why this hasn't been addressed as yet.
Do you know how long it would take for your T to reach castrate levels?

IIS - Getting closer, the first two pathology sections appear to be identical as well. I am not sure why pathologists do that but it is common in reporting templates to have a summary followed by a detailed breakdown which may be the same sometimes. We used to call it padding to make a report thicker when you charge lots of money and no one wants to read the whole report, just guessing.

I think you have all the important important information from a prostate biopsy. Usually they can only state the results of each core sample and some observations.

Given the references to “cribiform”, “intraductal”, “Paneth-like cells” with the G7 and G8 grading, I would suggest having them send the slides the Dr. Epstein’s group at Johns Hopkins for a second opinion. You want to make sure you have the pathology dialed in before making treatment decisions in my opinion. The link below is all they will need.

https://pathology.jhu.edu/patient-care/second-opinions

Halbert, you previously gave me a recommendation on a surgeon at Siteman, but there seems to be a consensus that surgery isn't going to be the path I have to travel. Did you also have a consult with a RO that you could recommend? I have 10 days until I get the CT & bone scans and then another 3 or 4 days before I have the sit down with the doc at St Lukes. In the meantime I think I'll try to set a consult with someone at Siteman. My only recommendation at St Lukes was a surgeon who performed his RALP without any resulting nerve damage.

Would appreciate a recommendation for a RO at Siteman from anyone going that route.

Thanks guys!

99 % of time I believe that second opinion on pathology is a waste of time. Not so much with you.
St. Louis has great options for cancer care.
My Best.
Hero

IsitSerious, as my signature shows, I also had blood in my semen and PC was not attacked until I was a Gl-8. My prostate was large and after having a TURP, triple play was not an option. My Uro was all for doing surgery, but said I might have to have an open surgery because of previous scar tissue. I talked with an RO and that IMRT and ADT was the way to go. I have finished my radiation and in one day will have been on ORGOVYX for two months. If this doesn’t work, he said there are many options to keep the cancer at bay. Your cancer may have spread already and mine as well. Your post suggests you have given up before you have started the fight. You are no where near hospice. There are many here that have cases much worse than ours and for much, much longer. This is not the end for you, it is just the beginning. The radiation was a non event for me. The forum here helped me through it. The ADT is just a nuisance, but a great tool to beat back this disease. As with any difficult situation, a positive outlook is always the best way forward. My best to you.
On a side note. I have been having symptoms of Covid. However, all tests were negative. They tested for the flu and it was positive. I have had all my vaccines, booster and flu shot. I wear a mask everywhere. My downfall was my pre-school granddaughter who we watch every week. Couldn’t help but to hug her, she’s so cute. A new SE for all on ADT. Try a fever with a hot flash at the same time. Glad I live in Arizona where working with temperatures over a hundred is the norm. LOL. For all that are experiencing the cold wave, my best to you.
Jack