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Posted 4/7/2022 10:43 AM (GMT 0)
Hello - been lurking and received my biopsy result... I have a tele meeting with the URO at Fox Chase in Philadelphia. I'm assuming I'm "unfavorable intermediate" since I had more than 50% positive cores and a lot of tumor locations - although at least 3 were targeted at the PIRADS lesion.

I'm in sort of freak out mode - leaning toward investigating SBRT and maybe even Proton - words of encouragement appreciated. Thank you!

@@@@@

Age 55. PSA 3.8 Family history. MRI showed 1 PIRADS 4 lesion, contained to prostate. Small prostate 21 CC measured on MRI. Some minor urinary issues - stream weakened over the years...

Source of Specimen(s):
1: Right posterior medial #1
2: Right posterior medial #2
3: Right posterior lateral #1
4: Right posterior lateral #2
5: Right lateral wing #1
6: Right lateral wing #2
7: Left posterior medial #1
8: Left posterior medial #2
9: Left posterior lateral #1
10: Left posterior lateral #2
11: Left lateral wing #1
12: Left lateral wing #2
13: Right apex PZ

Final Diagnosis:
1. Prostate, right posterior medial #1, biopsy:
- Benign prostatic tissue; no tumor seen.

2. Prostate, right posterior medial #2, biopsy:
- Rare atypical small glands present.

3. Prostate, right posterior lateral #1, biopsy:
- Benign
prostatic tissue; no tumor seen.

4. Prostate, right posterior lateral #2, biopsy:
- Prostatic adenocarcinoma, Gleason score 6 (3+3) [Grade group 1],
involving 1 of 1 core and approximately 40% of the tissue,
discontinuously.

5. Prostate, right lateral wing #1, biopsy:
- Prostatic adenocarcinoma, Gleason score 7 (3+4) [Grade group 2],
involving 1 of 1 core and approximately 60% of the tissue,
discontinuously.
- 10% of pattern 4 identified in Gleason score 7 cancer.

6. Prostate, right lateral wing #2, biopsy:
- Prostatic adenocarcinoma, Gleason score 7 (3+4) [Grade group 2],
involving 1 of 1 core and approximately 20% of the tissue,
discontinuously.
- 20% of pattern 4 identified in Gleason score 7 cancer.

7. Prostate, left posterior medial #1, biopsy:
- Benign prostatic tissue; no tumor seen.

8. Prostate, left posterior medial #2, biopsy:
- Benign prostatic tissue; no tumor seen.

9. Prostate, left posterior lateral #1, biopsy:
- Prostatic adenocarcinoma,
Gleason score 6 (3+3) [Grade group 1],
involving 1 of 1 core and approximately 10% of the tissue.

10. Prostate, left posterior lateral #2, biopsy:
- Scant atypical small glands, suspicious for adenocarcinoma.

11. Prostate, left lateral wing #1, biopsy:
- Benign prostatic tissue; no tumor seen.

12. Prostate, left lateral wing #2, biopsy:
- Benign prostatic tissue; no tumor seen.

13. Prostate, right apex PZ, biopsy:
- Prostatic adenocarcinoma, Gleason score 7 (3+4) [Grade group 2],
involving 3 of 3 cores and approximately 80% of the tissue.
- 25% of pattern 4 identified in Gleason score 7 cancer.

Summary of additional features:
Perineural invasion: present
Cribriform pattern 4: present
Intraductal prostatic adenocarcinoma: absent
Posted 4/7/2022 11:00 AM (GMT 0)
Hello Bob and welcome to the club nobody wants to join. Sorry you need to be here but we will help you any way we can.

The first thing I suggest is to get your biopsy slides sent to Dr. Epstein at Johns Hopkins. He is THE expert on prostate pathology and his reading will give you the best pre-treatment assessment possible. His assessment is unlikely to change the decision that you need treatment; you just want to make sure it's not worse than you think.

Next, please take the opportunity to get educated about our disease. You can start with the sticky thread at the top of our forum. From there I can recommend three books to read. Dr. Walsh's, "Guide to Surviving Prostate Cancer" is excellent but has more of a surgical slant. Two books by Dr. Scholz give broader perspective: "Invasion of the Prostate Snatchers" and "Keys to Prostate Cancer".

Then you will want to seek advice from several experienced docs whose specialties are likely to cure you. Your uro is likely to recommend surgery which is of course a viable option. But your case is also likely to be cured by radiation. Your mention of SBRT is a good place to start but don't forget to check out HDR Brachytherapy as well. Proton is no more effective than those choices, may not be covered by your insurance and is a lot more trouble.

Good luck. You have some time to get this right and you will. It's a big deal to make the treatment decision so seek out the experienced docs and weigh the important factors. Cure is first but also consider side effects.

Jim
Posted 4/7/2022 11:42 AM (GMT 0)
Thanks for the welcome Jim. Yes - I've done some lay research on SBRT... seems that UCLA has gotten good results even in high risk cases and the MRI guided version of the treatment is helpful with toxicity.

After I speak with the URO, I will ask for a RO appt with someone Fox Chase - they have a good reputation and hear them out before venturing off on my own.
Posted 4/7/2022 12:38 PM (GMT 0)
Bob,

Welcome from another greater Philly guy--I live up in Bucks Cty. Fox has a great reputation--they are certainly on the short list of great places to go. For completeness, I'd call Penn as well. I'd also second the suggestion to have a second opinion on your biopsy results from Johns Hopkins. Some percentage of the time there is a diagnostic change from the second read.

Actually, you're more likely Low-Intermediate, because your G7 is 3+4, not 4+3. Either way, while treatment is in your future, you have (some) time to research your options and make a solid informed choice. SBRT is certainly a great option for you, 5 treatments over 2 weeks and you're done.

If you'd like to make personal, local contact, maybe meet for coffee sometime, click on my name over on the left and my email is in my profile.
Posted 4/7/2022 1:22 PM (GMT 0)
“ Your mention of SBRT is a good place to start but don't forget to check out HDR Brachytherapy as well.”

I know Fox Chase has a superior HDR brachytherapy program. They don’t even do LDR there, feeling HDR is superior. Definitely ask.

Sending strength, PhillyBob
Posted 4/7/2022 1:32 PM (GMT 0)
Thanks Halbert - it would be nice to connect with someone - I'm actually in Bucks too.

And will do on sending the slides to Dr. Epstein and getting a Penn consult.
Posted 4/7/2022 1:35 PM (GMT 0)
CentralPADude - thanks for the strength - still a bit in freak out mode this AM smile.

I will ask about getting a HDR brachytherapy consult when I have my Fox Chase uro biopsy review call tomorrow. Googling now...
Posted 4/7/2022 1:40 PM (GMT 0)
Welcome Bob and glad to meet you. You’ve already acquired some good information and appear on good track. I’m an SBRT guy with excellent results and would be glad to help fill in any questions you may have. My urinary, sexual, and bowel function was excellent both prior to and following treatment and they remain the same today. I should qualify that by adding ‘for my age’. Very few have the stamina we did as in our twenty’s.

You mentioned some mild urinary issues and with the size of your prostate it does not seem to be related to BPH. It’s probably a good time to take that into consideration regarding your choice of treatment. Any of the radiation options is likely to offer a very high probability of a cure. I always recommend seeking out the very best practitioner and team for whatever choice you make and you’re blessed with some excellent choices in your area. Good luck and keep learning. Terry
Posted 4/7/2022 1:49 PM (GMT 0)
Thanks Terry... my MRI did note "mild BPH"... evidence of chronic prostatitis... and:

URINARY BLADDER: Moderate bladder wall thickening and trabeculations, likely
secondary to
combination of underdistention and chronic urinary bladder outlet
obstruction.

So I have all that going for me smile
Posted 4/7/2022 1:59 PM (GMT 0)
Assuming for the moment that a 2nd opinion from an expert such as Dr. J. Epstein at Johns Hopkins confirms the Gleason scores of your cores, it is not easy to know which of your two Gleason patterns, 3 or 4, predominates if your entire prostate were examined (as it is for men choosing surgery). Many 3+4 men are upgraded to a more serious 4+3, just as some are downgraded from 4+3 to 3+4. In other words, knowing which pattern is >50% in each tiny core of tissue (cores that are only partly cancer in almost cases) isn't always a good predictor of which pattern predominates throughout the entire prostate.

What may be just as important as knowing the exact Gleason score of your worst (highest-grade) lesion (if not even more so), is the potential of your particular cancer to metastasize. This can be estimated with a genomic test that can be done on biopsied tissue (e.g. Decipher Biopsy, OncotypeDx, and Prolaris) or on your whole prostate if you choose surgery (Decipher RP). These tests examine the RNA of your cancer cells and provide a statistical risk of your developing metastases and the risk of adverse findings, like tumor extension through the prostate capsule and growth into the seminal vesicles. (If, based on your biopsy and imaging, you decide you'll want treatment (probable IMO) and *IF* you know you want surgery, I suggest waiting to do a genomics test until after your surgery. The Decipher test done on post-RP tissue is more reliable than a test done on biopsy tissue, since the latter may have missed all of your highest-grade lesions.)

While you are waiting for your 2nd opinion on your slides, read up on treatments (RT vs. surgery, as well as the various RT modalities), ask question of us and the docs you consult with, and start a written list of these questions. As you get answers, you'll have new, more specific questions. That's the nature of our disease: lots of question, not all of which have clear-cut answers.

Djin
Posted 4/7/2022 2:11 PM (GMT 0)
Thanks Djin - I appreciate the advice. I will ask for a decipher or the like test be done when I talk to the URO tomorrow.

I guess I should ask or will be ordered a bone scan ?
Posted 4/7/2022 2:15 PM (GMT 0)

PhillyBob said...
Thanks Djin - I appreciate the advice. I will ask for a decipher or the like test be done when I talk to the URO tomorrow.

I guess I should ask or will be ordered a bone scan ?

Usually a bone scan is done only if the biopsy is G7 (4+3) or higher. The newer PSMA scans are much more sensitive than bone scans for picking up mets and not only in bone, but also in soft tissue, and throughout the body as well. They may replace bone scans entirely in the near future. IMO, decisions about further imaging should IMO wait until after the 2nd opinion.

Decipher done on biopsy tissue agrees with the test done on the same man after surgery (only) 70% of the time, for the reason I mentioned above. Discuss with your docs the value of a genomic test now vs. waiting. Note that the other 30% probably all consists of cases where the Decipher RP test showed a greater risk, not a smaller one.

Djin

Post Edited (DjinTonic) : 4/7/2022 10:32:24 AM (GMT-6)

Posted 4/7/2022 2:23 PM (GMT 0)
Djin, so if Epstein were to upgrade the Gleason to 4+3, a PSMA scan would be prudent?

(trying to get the hang of quoting but gave up..)
Posted 4/7/2022 2:29 PM (GMT 0)

PhillyBob said...
Djin, so if Epstein were to upgrade the Gleason to 4+3, a PSMA scan would be prudent?

(trying to get the hang of quoting but gave up..)

Bob, please remember we are not doctors. I try to give information that help guys ask questions and bring up topics with their docs--and to do their own research as well. In the case of 4+3 biopsy, a PSMA scan might be prudent, but I don't know current thinking/standard of care regarding PSAMA-PET scans in the diagnostic phase. A genomics test could inform that decision. If, say, your imaging shows no sign of enlarged lymph nodes and/or local spread of the cancer, your bone scan is negative, and a genomics test comes back low risk for mets, your doc may not advise a PSMA scan.

Perhaps other Forum Brothers can tell you their experience with these scans in the diagnostic stage.

Djin

Post Edited (DjinTonic) : 4/7/2022 10:33:50 AM (GMT-6)

Posted 4/7/2022 2:33 PM (GMT 0)
Understood Djin - thank you.
Posted 4/7/2022 3:45 PM (GMT 0)
Welcome PhillyBob and sorry you're the latest member of our club. And I think pretty much everyone here can relate to your description of this time as your "freak out" period--I know that sure described me. (I actually cycled a bit between freaked out and depressed.)

You've been given some great advice up thread and I'm glad you're prepping for your meeting with you uro. If there's a consistent thinking here it's that you want to meet with multiple experts and know all of your options before making any decisions. Unlike some cancers, you have multiple treatment options--and with your diagnosis pretty much all of them are likely to cure you. And PCa is slow growing--while I'm sure you'll want to move quickly, you do have some time to consider your options.

You're going to have to go down the rabbit hole in the months ahead, but the chances are excellent that you'll emerge from it in great shape. I hope we can help with your journey.
Posted 4/7/2022 6:04 PM (GMT 0)
Thank you Michael - the replies help and I've already learned a lot from lurking. I'll choose a nice red wine tonight and prepare my questions for the URO tele-meet tomorrow.
Posted 4/7/2022 7:00 PM (GMT 0)
Bob - After my diagnosis, I wish some prostate veteran would have come along and slapped me upside the head and said I am not going to die in the near future from prostate cancer. Somehow doctors, all the reading of published works, and the following forums are no substitute for the slap in the head by a real veteran. I suggest you take one of the local guys (mattam) up on their offer to meet up with you and maybe become your confident for questions you have that don't feel right on a forum, it will settle you down quickly. I have had some recent one-on-one experience with a newbie and he really seemed to appreciate the ability to fire questions at me any time before and after treatment and he went to Mayo.

Back to the subject - You noted "Cribriform pattern 4: present" in your biopsy pathology. This is one of those observations that is a evaluation factor and points to getting a second opinion from Dr. Epstein's group at J Hopkins and a genomic test (Decipher or?) on the cancer. That should be on your list to discuss with your Uro tomorrow. Otherwise, your pathology is pretty much in the middle of pack at this point.

I may be wrong but I do not think the new PSMA tracer PET scans are approved for general use in prostate diagnosis yet even though they should be. Another item for your list with the doctors as you never know if someone has a trial going for PSMA scans. Good luck tomorrow...
Posted 4/7/2022 7:54 PM (GMT 0)
Thanks Mumbo.

Noodling a bit, I would assume that any good RO would treat based on assuming my 3+4 really could be 4+3 no?

So, aside from possibly ruling out surgery as a monotherapy, it seems like that 4+3 really brings a dose of ADT into the picture. I've read some studies that debate its merit for truly unfavorable intermediates, but that seems to be the standard of care.

Regardless, no harm in getting an Epstein opinion - the time for blissful ignorance has passed smile
Posted 4/7/2022 8:49 PM (GMT 0)
Your biopsy is not alarming; Decipher and Epstein are mandatory, PSAMA-PET scan would be premature; and deep dive into treatment options should start soon.

No obvious solutions, no absolute answers, no silver bullets, but lots of fine advice above. Oh, there is no 'cure' for prostate cancer, but long term or even lifetime remission is a real possibility. That's why we stay vigilant.

All IMHO, of course. Good luck tomorrow. You'll be well prepared.
Posted 4/7/2022 8:58 PM (GMT 0)
Thanks garyi... as Mumbo pointed out.. the "Cribriform pattern 4: present" is a bit worrisome as I google it...
Posted 4/7/2022 10:05 PM (GMT 0)
The genomic testing (Decipher) will help assess the cribriform notation in context with other info. It is just another one of those items to be assessed. This is where the second opinion helps verify or not verify these factors so you can get on with the proper treatment.

My experience is that the doctors will treat what they think the situation is based on the data obtained at that time. Makes no sense but you need to push to insure that all possible data is obtained and verified when possible. The doctors will let you know if there are insurance issues or other reasons not to do something that you request.
Posted 4/7/2022 10:40 PM (GMT 0)
Thanks Mumbo - it appears just another risk factor (I'll throw it on the pile) smile
Posted 4/8/2022 6:01 PM (GMT 0)
PhillyBob -- I'm new to PCa as well, but might be able to offer a few words of encouragement. Your biopsy came back much like mine -- nothing higher than 3+4=7, but broad enough to put me into the "unfavorable intermediate" category. Here are my thoughts (and I'm not a doctor nor do I play one on TV):
1. You don't appear to have a five-alarm fire going on and almost certainly aren't going to keel over from this, and the odds of successful treatment are going to be well in your favor. Odds are you will die one day WITH PCa, not from it. It does, of course, have to be treated.
2. In addition to the advice already provided about having your slides further examined, be absolutely certain to fully explore the treatment options. And if you explore the surgery option, ask the doctor to run the Memorial Sloan Kettering prediction tool against your stats. This will give you a rough, generalized view of where you might stand with regard to surgery. Here were my results:
- Probability of cancer-specific survival after RALP: 10 yr/99 percent, 15 year/99 percent
- Progression-free probability after RALP: 5 yr/91 percent, 10 yr/85 percent
- Organ-confined disease probability: 57 percent.
- Extracapsular extension probability: 41 percent.
- Lymph node involvement probability: 4 percent.
- Seminal vesical invasion probability: 4 percent.

Aside from the fact that these are just generalized numbers, here's what these stats tell me: I'm going to live. In fact, at 63, I might outlive the disease and simply die with it. However, there is a 43 percent chance that my PCa is not actually organ-confined, which means that at some point in the future I might need additional treatment.

A good surgeon will tell you that these are just numbers, and your mileage may vary. But they will also tell you that, as far as generalizations go, they're pretty good.

Sorry you've had to join our club, and I hope you'll find some encouragement here. We're all in this together.
Posted 4/8/2022 7:56 PM (GMT 0)
AZRR - thanks for the thoughtful reply... I plugged my #'s in the MSK tool and it spit out basically the same result as yours ... I follow your thought process and how you arrived there...

I feel much more optimistic since my original post in large part because of the support and info in the replies I received.

Thank you.

(My biopsy results tele visit was rescheduled for next week with the URO)
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