5 year results

Hi Kindnesswinsoverall and Welcome to the Forum!

Not all G6 men are considered good candidates for entering (or remaining on) AS. I believe some of the factors considered are total tumor burden (number and size of one's lesions) and location (e.g. uni- or bilateral). (A PSA that has increased above 10 will also bump you off the stricter protocols, but that isn't a problem in your case). AFAIK, I don't think you would be advised to enter AS if you had five G6 lesions, especially if they are bilateral.

The issue here is not so much one's existing G6 lesions. It is true that G6 cannot metastasize (although it can sometimes grow contiguously out of the prostate in the form of extraprostatic extension and perhaps into the bladder neck). Rather, the larger the G6 tumor burden, the greater the risk that your currently harbor higher-grade lesions or microlesions that are being missed by imaging and biopsies. Cancer is a heterogeneous disease: it's not uncommon to develop lesions with different Gleason makeups.

As you know, a biopsy samples only a tiny amount of tissue. Perhaps one-third of G6 men who choose surgery learn from their post-op path report they had some pattern 4 somewhere in their prostate and that their Gleason score was upgraded (i.e., they were not a 6 but rather a 7 or higher). Even if a core taken from a lesion is all G6, this doesn't mean that there is no pattern 4 elsewhere in that lesion.

The goals of the better (stricter) AS programs are (1) to keep men who don't need treatment in the program, but also (2) to prevent men from falling through the cracks by being found to have higher-grade lesions that have metastasized too late to benefit from curative treatment. Looking forward, you don't want unnecessary surgery. But you also don't want to wind up in a position where you do have surgery down the pike, only to find you are, say, a G8 (5+3), it has metastasized, and you are left wondering how things would be different if you had sought treatment earlier.

Look up, or ask for, Mayo's current criteria, for remaining in their AS program. If they are advising you seek treatment, it may not be a push for surgery as opposed to some form of treatment (RP or RT). On the other hand, your docs may feel you are on the borderline between remaining on AS and needing treatment. Of course, no one will force you to do anything. If you do remain on AS, be sure to follow the protocol closely. Perhaps your next biopsy could be a saturation biopsy rather than 12-14 cores.

Finally, you may want to inquire about the benefit of having a genomic test (e.g. Decipher Biopsy or Oncotype Dx) done on your latest biopsy tissue. These tests analyze the RNA in your cancer cells. about 10% of G6 men turn out to be high-risk on the Decipher test for developing higher-grade lesions and metastases within 5 years. In addition, these genomic tests also give you the risk that you are currently harboring clinically significant Gleason pattern 4 or 5.

Don't be shy about asking your docs direct questions, such as "Are you advising me to treat my cancer now?"

Keep us posted, please. All the best,

Djin

Somewhat as an aside, there are other (mostly radiation) options for tackling (low-grade) prostate cancer, although at your young age, surgery may be the preferred one.
PS: The earlier posts offer excellent advice, IMHO.

Kindness, I have not much to add, just a welcome from me as well. The two things I would emphasize, among the many excellent responses you have received, are 1. second opinion from Epstein at Johns Hopkins, and 2, Decipher test on the positive tissue. I think a Decipher test could be very informative.

I'd also want a saturation biopsy, to hopefully, give more confidence on staying on AS
Good luck

Hi,

We keep advising people to get a second opinion on their biopsy from Dr. Jonathan Epstein at Johns Hopkins. I too have enormous respect for Dr. Epstein and I too got a second opinion from him directly (I wound up speaking with him on the phone). However, it has come to my attention that Dr, Epstein might have taken a leave from Johns Hopkins. There has been no confirmation of this and no explanation. I don't know what his status is at present.

I assume you can still get a second opinion from the Johns Hopkins pathology team, and I assume the team's members were trained by him. Whether Dr. Epstein is still part of the team is not clear to me.

After three years of AS as a Gleason 6, I had a biopsy showing three positive cores, bilaterally, with involvement between ten and twenty percent.

This caused concern, and my case was the centerpiece of Johns Hopkins weekly review of their urology cases. I understand that all the big players were there. The decision was to have me take the OncotypeDX genomics test, which JH was reviewing for the FDA.

I got a GPS score of 2, out of 100. Probably the lowest GPS score of any diagnosed man ever tested. I stayed in the AS program.

That was in 2012, and the test proved true, as my last two biopsies and a post-op pathology from my aquablation procedure found no cancer.

My advice to you is that a genomics test, such as Decipher, OncotypeDX, or others, can be pivotal in raising confidence in your AS decision.

Hello Kindnesswinsoverall (btw - great screen moniker!)

I was just treated last month at Mayo Rochester after my PSA spiked exponentially in February / March.

You're in great hands there. Among the many reasons the Mayo is consistently noted as the leading medical center in the world: their long-standing culture of focus on the needs of the patient first, and their remarkable research agenda.

It's possible that there are other factors in your biopsy beyond the Gleason numbers which are influencing your team's recommendations. My MRI showed only a small lesion on one side; biopsy indicated one G6 & three G7 (3+4) cores on that side but with "Perineural invasion" there, and also noted "High grade prostatic intraepithelial neoplasia" on the other side, which is a precursor to malignancy. They consequently recommended strongly against AS -- or any "Focal" treatments for that matter, based on these non-numerical factors.

After closely considering their Proton Beam treatment, I opted for surgery for a variety of reasons, but primary was my surgeon's (Igor Frank MD) experience and his cutting-edge research work with the newest robotic machines. The single-port Da Vinci system was only introduced in 2018 but by 2019 he had already published studies showing the promise of new techniques, made possible by the machine, with lower SEs, faster operating time, and less blood loss. (Didn't really care about fewer incisions... but it's only 2 instead of 6.)

I woke up the morning after my procedure with a spontaneous erection straining against the catheter. Me, my wife, and Dr Frank all shared great big grins at this marvelous sign.

My post-op pathology report validated the decision to remove the thing: it came back considerably worse than my biopsy. I was pT3, with extraprostatic extension; cribriform morphology, and the other side of my prostate from the primary tumor now had *two* small malignant lesions where the area of "neoplasia" had been 10 weeks earlier at biopsy.

But I had clear / negative margins! So, touch wood (pardon the pun), it's possible I'm done with treatment. My erectile function is same as pre-op (I'm 65 & already needed a low dose of Viagra for full-tilt), and now that I'm 3 weeks out from surgery, my continence is nearly fully recovered -- I was only catheterized for 5 days post-op. Statistics are on my side that within a short while I'll be completely back to normal there too, so on the balance of cancer-control, ED, and continence, I'm happily close to a trifecta.

Dr. Frank used the sp-RALP system to do a Retzius-sparing, pre-peritoneal Hood technique for my procedure. There are anatomical and tumor-location criteria, so ask your doctors if you're a candidate for this approach. It avoids damaging structures at the front of the prostate & bladder associated with continence issues, and would make the surgical option considerably less invasive for you.

best of luck,

nels

Case NumberView trends

Value

SR-23-19285

Report electronically signed byView trends

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Rumeal D. Whaley, M.D. I verify that I have examined all relevant slides/materials for the specimen(s) and rendered or confirmed the diagnosis.

Gross DescriptionView trends

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A: Received on a biopsy board filled with formalin labeled with the patient's name, medical record number, and specific prostate sites aresix pink tan tissue cores. A. Received within the first well is a complete core 1.3 cm in length labeled "right posterior medial apex, prostate" per biopsy board. B. Received within the second well is a complete core 1.4 cm in length labeled "right posterior medial base, prostate" per biopsy board.The core is inked green. C. Received within the third well is a complete core 1.5 cm in length labeled " right posterior lateral apex, prostate" per biopsy board. Thecore is inked blue. Specimens A, B, & C are submitted in cassette A1. D. Received within the fourth well is a complete core 1.6 cm in length labeled " right posterior lateral base, prostate" per biopsy board. E. Received within the fifth well is a complete core 1.5 cm in length labeled "right anterior horn, prostate" per biopsy board. The core isinked green. F. Receive d within the sixth well is a fragmented core 1.6 cm in length labeled " right anterior apex, prostate" per biopsy board. The coreis inked blue. Specimens D, E, & F are submitted in cassette D1. Grossed by CGL. G: Received on a biopsy board filled with formalin labeled with the patient's name, medical record number, and specific prostate sites aresix pink tan tissue cores. G. Received within the first well is a complete core 1.8 cm in length labeled " left posterior medial apex, prostate" per biopsy board. H. Received within the second well is a fragmented core 2.5 cm in length labeled "left posterior medial base, prostate" per biopsy board.The core is inked green. I. Received within the third well is a complete core 1.2 cm in length labeled "left posterior lateral apex, prostate" per biopsy board. Thecore is inked blue. Specimens G, H, & I are submitted in cassette G1. J. Received within the fourth well is a complete core 1.2 cm in length labeled "left po sterior lateral base, prostate" per biopsy board. K. Received within the fifth well is a fragmented core 1.9 cm in length labeled "left anterior horn, prostate" per biopsy board. The core isinked green. L. Received within the sixth well is a complete core 2.1 cm in length labeled "left anterior apex, prostate" per biopsy board. The core isinked blue. Specimens J, K, & L are submitted in cassette J1. Grossed by CGL. M: Received in formalin labeled with the patient's name, medical record number, and "prostate needle biopsy-right anterior medial" are 2pale tan soft tissue cores, measuring 0.1 cm in average diameter and 0.8 cm and 1.3 cm in length. Specimens are submitted en toto incassette M 1. Grossed by CGL. N: Received in formalin labeled with the patient's name, medical record number, and "prostate needle biopsy-left anterior medial" are 2pale tan soft tissue cores, measuring less tan 0.1 cm in average diameter and 0.5 cm and 1.2 cm in length. Specimens are submitted entoto in cassette N 1. Grossed by CGL.

InterpretationView trends

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FINAL DIAGNOSIS A. Prostate, right posterior medial apex, needle core biopsy: Benign prostatic tissue

B. Prostate, right posterior medial base, needle core biopsy: Benign prostatic tissue

C. Prostate, right posterior lateral apex, needle core biopsy: Benign prostatic tissue

D. Prostate, right posterior lateral base, needle core biopsy: Benign prostatic tissue

E. Prostate, right anterior horn, needle core biopsy: Prostatic adenocarcinoma Type: Acinar Gleason score 3 + 3 = 6 Grade Group: 1 Tumor involves 5% of overall specimen (1 of 1 core).

F. Prostate, right anterior apex, needle core biopsy: Benign prostatic tissue

G. Prostate, left posterior medial apex, needle core biopsy: Prostatic adenocarcinoma Type: Acinar Gleason score: 3 + 3 = 6 Grade Group: 1 Tumor involves 30% of overall specimen (1 of 1 core).

H. Prostate, left posterior medial base, needle core biopsy: Prostatic adenocarcinoma Type: Acinar Gleason score: 3 + 3 = 6 Grade Group: 1 Tumor involves 10% of overall specimen (1 of 1 core).

I. Prostate, left posterior lateral apex, needle core biopsy: Prostatic adenocarcinoma Type: Acinar Gleason score: 3 + 3 = 6 Grade Group: 1 Tumor involves 20% of overall specimen (1 of 1 core).

J. Prostate, left posterior lateral base, needle core biopsy: Prostatic adenocarcinoma Type: Acinar Gleason score: 3 + 3 = 6 Grade Group: 1 Tumor involves 30-35% of overall specimen (1 of 1 core).

K. Prostate, left anterior horn, needle core biopsy: Prostatic adenocarcinoma Type: Acinar Gleason score 3 + 3 = 6 Grade Group: 1 Tumor involves 5-10% of overall specimen (1 of 1 core).

L. Prostate, left anterior apex, needle core biopsy: Benign prostatic tissue

M. Prostate, right anterior medial, needle core biopsy: Benign prostatic tissue

N. Prostate, left anterior medial, needle core biopsy: Benign prostatic tissue

I'm going to try that genomic test. See what Mayo will offer. If they offer nothing I'll send it off if that's an option.

Thank You so much for all the great advice.

I share DJin’s concern with this biopsy finding six positive cores bilaterally.

That raises your risk from very low to low, providing more motivation for additional data such as a genomics test.