Need Help Understanding Core Percentages

Hi AZ. Here's my take. The number of positive cores speaks to me more than the percent cancer of the invidivual cores. Your cancer is bilateral and there appears to a large tumor burden (the percentage of the prostate that is occupied by malignant tissue, which is not reported in a biopsy).

When there are just a few cores, the percent cancer of each core is fairly unreliable, because it can also depend on the orientation of the biopsy needle relative to the shape and position of the lesion (the needle can go through the thin part of a lesion, just nick it, or skewer the same lesion along it's longest dimension, all in different percentages for the same lesion). Also, any given core could have hit a small or large lesion, which obviously also affects the percent cancer.

Usually it's hard to know which Gleason pattern (3 and 4 in your case), is actually the predominant one prostate-wide, which is why many men have their Gleason scores up- or down-graded after RP (if they choose surgery, that is). Does your biopsy report give the percentage of Pattern 4 in each core? IMO, this is more important than the percent cancer of each core. Right now your G7 (3+4) puts you in the Favorable Intermediate Gleason Grade Group. However, it can't be excluded that your actual Gleason score is G7 (4+3), if the actual prostate-wide amount of Pattern 4 is greater than that of your Pattern 3.

I suggest you have all your slides sent to Dr. J. Epstein at Johns Hopkins for a 2nd opinion. It is often covered by insurance, and is not expensive even if you have to pay out-of-pocket. This would ensure that you have no Pattern 5 in any core and that no core is 4+3. A a bone scan is usually done for men with a biopsy score (highest-grade core) of G7 (4+3) or higher, whereas it is usually not for G7 (3+4).

IF your cancer is prostate confined (imaging will help estimate this), the fact that your cancer is bilateral has no statistical correlation with your outcome. I just saw a paper that estimates that men who have surgery with a perfect outcome (prostate-confined pT2 status and no positive surgical margins) have only a 5-10% chance of biochemical recurrence (a rise in PSA over 0.2) in their future. Of course radiation provides equally good outcomes, the difference being with RT you have only a rough idea of the prostate-confined status as judged by imaging.

Djin

If you have chosen RP, you will have a detailed post-op report with your final (actual) Gleason score. You could say that prior to surgery tumor burden (percent of the prostate occupied by cancer) is correlated with adverse findings found at the time of surgery (growth outside the prostate capsule, into the seminal vesicles, into the bladder neck), but again, percent cancer in each core may or may not be correlated with the actual overall burden.

I had two positive biopsy cores of 14 total: my G10 (5+5) core was 50% cancer; my G9 (4+5) was 2% cancer, yet my final Gleason score was G9 (4+5). My post-RP report estimated that my tumor burden (percent of my prostate that was cancerous) was only 5%. You could say the percentage of positive cores was more of an indication of the extent of my cancer than the percent cancer of each core.

Also, the more your biopsy cores vary in their percent cancer, the poorer an indication they are of your overall tumor burden. If all ones' cores are, say, 80% cancer, it says more than if one's percentages are all over the place, e.g. 5 to 80%.

Once you have your final path report with your actual Gleason score and your final path staging, the overall tumor burden is a factor (less is better), but your biopsy findings, including the percent cancer of each core especially, are of little import, IMO.

The bottom line is that for those who opt for RT as their primary treatment, their biopsy report is of primary importance for treatment. If you opt for RP, the biopsy report is essentially replaced by the post-op pathology report. Your outcome is measured by your

Path Staging:

-- Final Gleason Score
-- Number and extent of any adverse findings (local growth outside the prostate and any more serious microscopic findings within the prostate itself)
-- Positive/negative status of removed lymph nodes
-- Tumor burden

and your

-- Post-op PSA

At that point, the percent cancer of your individual biopsy cores will of no importance at all, AFAIK. Right now, it is only a statistical indicator of what your findings at surgery might be.

Please ask your uro about these any any other questions that concern you. The above is my opinion/understanding. We are not doctors!

Djin

RP does have the advantage of a detailed pathology of all the tissue removed. However it comes with no guarantees regarding what was remaining. I found it frightening to look at so many stories and signatures here of men following RP who had recurrence and follow up radiation, ADT, and side effects that I had to ‘look up’ to understand. It caused me to dig deeper into treatment options. A lot of these guys were told at the time of surgery everything was clean and we believe we got it all.

I urge every recently diagnosed guy to make a fully informed decision including radiation options. If you’ve only discussed treatment with your Urologist you may not be fully informed.

Terry's Cellar said...
RP does have the advantage of a detailed pathology of all the tissue removed. However it comes with no guarantees regarding what was remaining. I found it frightening to look at so many stories and signatures here of men following RP who had recurrence and follow up radiation, ADT, and side effects that I had to ‘look up’ to understand. It caused me to dig deeper into treatment options. A lot of these guys were told at the time of surgery everything was clean and we believe we got it all.

I urge every recently diagnosed guy to make a fully informed decision including radiation options. If you’ve only discussed treatment with your Urologist you may not be fully informed.

Agree -- everyone should look at all options before making a decision. I jumped onto the RT bandwagon almost immediately, but when it became clearer about the extent of my PCa and the ramifications of going to radiation first in my case, I backed away from that. My urologist (who doesn't do the surgery or radiation himself), GP, and the surgeon himself all laid out the facts and the choice for me was clear: RP.

azroadrunner said...
My urologist (who doesn't do the surgery or radiation himself), GP, and the surgeon himself all laid out the facts and the choice for me was clear: RP.

Runner, if you have made a hard and fast RP decision then I wish you the best of luck and hope you have 100% success. But I would be remiss if I didn't tell you that if you have only spoken with urologists and a GP about radiation and have not consulted directly with RO's then you probably haven't really done your homework. Even the most ardent surgery guy on our forum will likely tell you that seeking out multiple opinions from different specialists is crucial to making an educated decision. They (and I) will also tell you not to get radiation advice from a surgeon nor surgical advice from a radiation oncologist. And GP's are notoriously ignorant when it comes to keeping up with modern treatment of prostate cancer. I say this as I see you repeating oft-quoted surgery sales pitches, e.g. "I'm having surgery because that allows me to have radiation later". Surgeons often tell their patients that to convince them to have surgery first...surgeons I consulted surely did. But what that omits is the true statement that there are as many good options for salvage after failed radiation as there are after failed surgery -- a good RO can inform you about that.

Anyway, this is the one and only time I will encourage you to complete your due diligence. One of our unwritten rules around here is to give support to men once they have made their decision. But another unwritten rule is to try to be as helpful as possible to men to make an educated decision. Sorry if this seems direct or unsupportive but I value the latter unwritten rule over the former. In 14 years on this forum I have never heard a member say he got too many opinions. I have often heard members say they didn't contact enough experts and made a decision w/o all of the facts.

Best of luck in any case.

Jim

azroadrunner said...


... but when it became clearer about the extent of my PCa and the ramifications of going to radiation first in my case, I backed away from that. My urologist (who doesn't do the surgery or radiation himself), GP, and the surgeon himself all laid out the facts and the choice for me was clear: RP.

Azroadrunner,
I'm not sure what you mean by the extent of of your PCa and the ramifications of going to radiation first in your case. It sounds like the surgeon's hardsale for surgery by dangling radiation as a backup. The question I would pose is that if your PCa is so extensive that you may need radiation to clean things up after surgery, why not just do radiation to begin with? Also, if you do in fact have "extensive" PCa I wonder if wider cuts may be required to get it all, increasing your chances for ED and incontinence. There's a lot going on in that part of a man's body to be sticking scalpels in there.

As others have said, only consulting with Uros and gps does not equal exploring your RT options.

If I have misinterpreted your situation, I apologize. If it seems like some of us are "piling on" your surgery decision, it's because this is one of the biggest choices you will ever make in your life.

I wish you the best with your treatment.

azroadrunner said...

Tudpock18 said...
Anyway, this is the one and only time I will encourage you to complete your due diligence.

Jim

Thanks, Jim. I will continue following-up to be absolutely certain. Prostate cancer -- and, in fact, cancer of any type, is brand new to me. Scary as well. I've been healthy my entire life -- until this. I'm here to pick up advice like what you and others provide, and read up on as much as I can.

Runner, thanks for receiving my comments so gracefully. Honestly, I was a little concerned about making them since you seemed pretty set in your decision. But if you do follow thru with RO's as part of your due diligence and then still decide to go with RP then I assure you that you will be even more certain that you have made the right decision and this will continue to take the "scary" out of this. In any case your cancer is highly likely to be curable and that's what all of us want for you!

Jim

Hi AZ, I'm about 2 steps farther down this road than you. My Uro suggested surgery without much discussion, and I was leaning heavily in that direction. It took a bit to get an appointment with an RO, and she spent a good bit of time with me talking about my situation, further testing (bone scan, Decipher), treatment options and side effects. I point blank asked her, can you kill my cancer and leave me with a high level of functionality? She looked me in the eye and said, yes, I feel very confident we can. I believe her. I have a follow up on the 29th to discuss the plan (awaiting Decipher results, bone scan was good). I haven't decided completely yet, but RT looks more convincing as the better option, for me anyway.

I'm not trying to persuade you in any direction, just offering my story, FWIW. Best of luck to you, my friend.

AZ, I'm in line with the other suggestions: especially to actually talk to RO's about radiation options. I'll go one further: if there is ANY doubt from an MRI or other scans that your PCa is NOT prostate confined--even if there is a slight bulge or concerns about lymph nodes, then surgery becomes less likely to become curative, and you'll need radiation later anyway.

The odds go even higher against surgery if you're G8 or G9--the likelyhood that it has moved out is higher.

And, I'm a surgery guy.

AZ, that's a good plan. One thing I've seen over and over again on this forum is this: Men who truly do their due diligence by talking to experts in all the available treatment modalities have much better mental/emotional outcomes than those who do not--regardless of their physical outcomes.

Oh, in another post you shared what I think is the worst half-truth sales pitch for surgery that is out there. The old "you can have radiation after surgery, but not surgery after radiation" line.

Here's the true part: Post radiation surgery is extremely challenging, with poor outcomes, because of the tissue damage from the radiation.

Here's the rest of the story:

If you really think it through, the statement suggests that it is likely that primary treatment (either radiation or surgery) will fail to provide cancer control. At your diagnostic stage, that is a pretty low probability...10% or less I think. It further says that after primary radiation, you have no additional treatment options. Also not true. Depending on your initial radiation dose and where the dose was focused, additional radiation is possible. Also, ADT and chemotherapy are legitimate, available options.

That statement is a scary sales pitch. Which I find to be deeply unprofessional at best. I heard it too. I had surgery, and my primary reason had to do with the logistical challenges of going through 6 weeks of radiation living where I was living at the time (an extremely rural area a 2 hr drive to the major hospital where treatment was available) in the middle of the midwest winter. I also wanted to know my final pathology (I'm one of the 10-15% who got a post surgery pathology upgrade). I'll say this: If SBRT (5 treatments over 2 weeks) had been used longer where I was treated before my time came, I likely would have gone that route. It was just coming online there for PCa, and I wanted to be more secure in the experience of the team.

AZ - As a survivor of da Vinci robot assisted prostatectomy and also robot assisted hernia repair, I can tell you the process is a neat concept like arthroscopy was for orthopedic surgery of which I have had a few also. The big advantage is that you avoid the cutting and opening of the body which always results in a lot of immediate post-op pain. However, the prostate surgery was much more involved and required a much longer surgery recovery than the others. Sure, it is remarkable to walk home the next day without any killer pain but it takes a long time to feel right again. Doesn’t make it a bad idea just understand that it is not as slick as it appears sometimes and is still a major complicated surgery.

You are receiving excellent advice to spend proper time getting assessments from board certified radiation oncologists regarding HDR brachytherapy, SBRT and tradition fraction IMRT, or some combination. Anything less will be shortchanging yourself on choosing a well researched and thought out treatment strategy and plan.

Any and every treatment will induce side effects and will take time away from other activities including work. I had two HDR-BT procedures and 25 IMRT procedures over six weeks and three years of ADT. During that time I missed a total of two days of work. Every surgery man I know of missed many more than 2 days of work.

Remember that radiation following surgery is far different than radiation as the initial treatment. When used as an initial treatment 90-95% of the radiation is to the cancerous prostate, which you are purposely trying to destroy, and largely spares benign tissue from damage. When you radiate where there is no prostate 100% of the radiation is to the benign tissue in search of little specks of PCa. The negative side effects are usually more significant. But, I am confident that your surgeon has already explained this to you.

I also am confident your surgeon has explained and helped you use the nomograms from Johns Hopkins and Memorial Sloan Kettering Cancer Center to show the probabilities of treatment success based on their extensive data bases and your diagnoses specifics. If he hasn’t, shame on him for being incomplete in his advice. If he hasn’t, then you should. They only take a few minutes and can provide you great data points to assist your decision treatment process.

You only get one shot at choosing your initial treatment method and then you have to live with the results. You mention your consulting work and from my business experience engaging consultants, the effective ones helped me understand all options with pros and cons and cost benefit of each before deciding and implementing the best choice. Please use that simple and effective methodology for choosing your treatment plan.