Biopsy Results Feedback requested

Lucky, welcome to the forum, as we always say, sorry you need to be here but glad you found us.
It looks like you've got 3 cores out of 17 positive for cancer, with Gleason 7 (3+4) which is considered low risk intermediate, (always use the highest grade) and that gives you lots of options. The perineural invasion means cancer was found along the nerves of the prostate (which i believe can potentially lead out of the prostate, not sure, someone else will confirm or refute), Most people think thats not very consequential, but there is some debate. The HGPIN and Atypical Acinar are abnormal cells which are not, but have the potential to turn into, cancer.
I, and most hear, would suggest you get the slides sent to Dr Jonathan Epstein and Johns Hopkins Pathology, they have a second opinion service. He is acknowledged as the top prostate cancer pathologist in the country, and its a very subjective process to grade prostate cancer cells. So i think its really important to get that opinion.
As i said, you've got lots of options from Surgery to Radiation of different types, and possibly, if Epstein downgrades the Gleason Grade, even active surveillance, meaning you actively monitor the cancers progress but do nothing for now.
I'll leave it at that for now, just know this is very different from most other cancers in that even the aggressive grades do not spread quickly and the vast majority have the potential to be cured (even though we dont like to use that word)
Stay tuned others, many more knowledgeable than me, will chime in, although it can be a bit quiet here on the weekends.

Lucky, Glad your looking for information. It appears from your husband’s biopsy results your husband will need some type of treatment. A very challenging aspect of this disease is that there are so many treatment choices to wade through and your urologist may not be familiar with a lot of them. Most urologist do surgery and have little expertise in the variety of radiation treatments available. Radiation oncologists each have their own specialty as well. There is no perfect choice, only the choice that’s best for your situation. More good news is that either surgery or a number or radiation choices offer high cure rates.

When I was diagnosed I found a lot of very good information on this forum. I had six weeks between the time of my biopsy results and my sit down with my urologist for treatment. I used that time to learn as much as possible about my choices. My wife is a nurse and was a big help with the medical terminology etc. and we attacked the problem jointly. When we finally did sit down with our urologist we had a pretty good grasp of our options. Our urologist offered surgery; but, recommended we also consult with radiation oncologists. In the end we opted for a form of beam radiation called SBRT (also known by other names). Five easy treatments with no impact to the good urinary and sexual function I had prior to diagnosis. Keep investigating….an informed treatment decision will be the best one.

I agree strongly with the suggestion that you get a second opinion on the biopsy from Dr. Epstein at JH.

With regard to perineural invasion (PNI), the majority of studies (but not all) I've seen concluded that PNI seen after surgery is not remarkable. I remember one study that found that more than 80% of men who opted for surgery had PNI somewhere in their prostates afterwards.

On the other hand, PNI seen at biopsy is correlated with adverse findings. This study found the rate of PNI found at biopsy to be between 7.0% to 33.0% in nearly 15,000 patients:

Impact of biopsy perineural invasion on the outcomes of patients who underwent radical prostatectomy: a systematic review and meta-analysis (Review, 2019)

"Conclusion: Evidence from the included observational studies indicated that biopsy PNI was not only correlated with adverse pathologic characteristics but also with worse BCR prognosis of local PCa after RP. The status of biopsy PNI could serve as a promising risk-stratification factor to help the decision-making process, considering active surveillance (AS) or further treatment for PCa patients."

I don't have the Full Text, but my understanding is based on the fact that prostate cancer has an affinity for invading the fine nerves within the prostate (and may be a pathway for spreading out of it). PCa has often been growing for some time before diagnosis and it's reasonable to expect that when the entire prostate is sampled and examined microscopically, PNI will be found somewhere. If it is seen anywhere in any amount, it scores as PNI+ in the post-RP report.

However, a biopsy samples a minute amount of prostate tissue, and if PNI is observed, you could infer that it may be widespread within prostate and that the cancer is more likely to have been growing longer, and/or is, perhaps, more aggressive.

Keep in mind that these studies are statistical in nature, and just up the risk factor for adverse findings (if one were to choose surgery, where the whole prostate is sampled). They do not mean that everyone with PNI at biopsy will have adverse findings or go on to biochemical recurrence (a future rise in PSA after primary treatment that may signal clinical recurrence).

You can discuss this finding with his doctors: they may be of a different opinion or, if they agree that the PNI does have significance, it could factor into weighing treatment options.

You can also confirm with his doctor that the 17-core biopsy was not "target-only," but rather sampled all 12 prostate zones, with some extra cores in some identified targets. Was this your husband's first biopsy? What prompted it and was there a prior MRI?

You might discuss the advantage of having a genomic test (such as OncotypeDx or Decipher) done on the biopsy tissue, especially if Dr. Epstein grades the biopsy as a (3+4) or a (4+3). Here too, knowing whether the risk of metastases within 5 years is low, intermediate, or high might also weigh on treatment options.

Djin

I strongly agree with the suggestion that you spend the next two weeks learning about different treatment options. There are a lot! Knowing more will make your conversation with the urologist more productive, because you will understand what he or she is saying, and will be able to ask better questions. As Jim says, many urologists are committed to surgery as a treatment and will disparage radiation. Be sure to get a referral to a radiation oncologist, so you will get both sides of the debate. With many illnesses, there is a standard treatment. Not so with prostate cancer, and that leaves the patient in the position of having to decide on a treatment.

Always good to relax… From experience, don’t overstudy the issue too much quite yet. Prostate cancer diagnosis and treatment is an ever changing situation in recent years and books can not be updated often enough. Depending on where your live may influence the doctor’s understanding of the latest ideas and methods.

Another thing that is recommended is to start a notebook/binder with all his test results, imaging reports, notes from visits, handouts, etc. for quick reference. This can be done on a computer also but you may have to scan things in from time to time and it needs to be portable for his visits. My wife has a BCa binder that goes back to 2003 which was really handy recently as it had old CT reports that can no longer be located nowadays. I have one also and a computer file.

Based on your biopsy values, you have >50% chance a higher grade cancer is present.

Htownman said...
I am curious as I am awaiting my latest biopsy results.

If PNI is present, will or how does this impact the success of nerve sparing in an RALP?

That's a good question. AFAIK, lesion/cancer location is the major factor in predicting bundle involvement. You may need a deeper dive into the papers on this topic. Usually your surgeon can give you a good initial evaluation of what to expect. For example, my uro/surgeon said he was fairly sure he would be able spare the neurovascular bundle on one side, but would not know about the other until the operation. In fact, he was able to spare both--the questionable side had a biopsy lesion in a top prostate zone, against which the bundles rest.

The question arises as to whether the higher rate of BCR seen in men with PNI at biopsy might be due, at least in part, to (perhaps microscopic) travel (via the bundle nerves) out of the prostate that has already occurred by the time of surgery.

IMO you should wait until your biopsy results are back before going down big or small rabbit holes

Djin

Thanks for your reply.

Still awaiting my biopsy results.