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Updated Biopsy Results

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Posted 2/8/2020 1:52 AM (GMT 0)
Just got an updated report of my biopsy pathology results now that Dana Farber has given the slides their own review.

No big difference in the bottom line but still some shift to the worse, I think. Now it is all 4+3 G7 in 10 out of 14 cores (all on left side) with PNI reported in three areas. The percentages in several areas are awful high— e.g., left lat mid shows 4+3 in two cores at 100% and 90% of the cores, respectively, with G pattern 4 comprising 80% of the tumor. I’m scratching my head wondering how those two cores can be so full of pattern 4 and still grade out at Gleason 7—any thoughts on that?

I’d been sort of thinking already that I may be close to G8 status, and this read seems to validate that thinking.

I’m wondering if it’s still worth sending the slides to Epstein for a third read. I suppose I will, but I’m thinking I may not be quite as comfortable waiting much longer before making a final treatment decision, since I seem to be carrying around a lot of G4 nasties. Still need to wait for the bone and CT scan results when I meet with the uro (Kibel) at Dana-Farber next week though.
Posted 2/8/2020 2:22 AM (GMT 0)
The second-most common pattern is listed regardless of the percentage of the dominant pattern. So if the second-most common is 3, the core will be G7 (4+3) even if it is 90% 4 and 10% 3. A grade would be G8 (4+4) only if there was no pattern 3 or there was very little. Many pathologist list a small presence (usually <5%) as a tertiary pattern e.g. G7 (4+3) + tertiary 5. However, they don't bother listing a "tertiary 3," because the pattern 3 is meaningless when patterns 4 and/or 5 make up 95% or more of the core (or whole prostate for a RP path exam).

Djin
Posted 2/8/2020 2:29 AM (GMT 0)
FreeWill, either way, you have a lot of G4 cells hanging around, which suggests that you need to deal with it forcefully, and soon. At least, that my opinion.

Now that you're at DF, you're in good hands, they will probably give you a shot of Lupron to hold things as they are while the details are ironed out. You'll be in for a rough ride for a while--but you'll come out on the other side.
Posted 2/8/2020 2:30 AM (GMT 0)
Seems similar to my biopsy pathology, most of the bad stuff was on one side and had some cores with high percentages. The high percentage of pattern 4 just means the core got a good sample in a bad area and it was mainly 4. Yes, it could be G8 but they probably saw enough pattern 3 to make that call.

The Epstein opinion is up to you. Not sure what they would come up with that would make a treatment difference but more info tends to be a good thing for your confidence. You can still move ahead while that is being done.

I agree that you need to be heading towards decision time and get a treatment plan going. Nothing gets better with time when it comes to cancer so it is getting near that time. My doctor said to take my time making a decision but not too much with this type of pathology. Sounds like you are in the same spot.
Posted 2/8/2020 1:19 PM (GMT 0)
Thanks guys. Guess I’d let myself go mentally “on vacation” from this business when they told me a week or so ago that I should be ok to take a few months to make a treatment decision. I may have heard that and let myself proverbially kick the can down the road a bit.

Probably a good thing to now get a kick in the pants to get my rear in gear.

If they start me on Lupron right away, how immediately are the impacts typically felt (based on your experience)?

Thanks
Posted 2/8/2020 2:34 PM (GMT 0)
Don’t jump to conclusions about Lupron quite yet. You will need to visit the doctors and see what they propose. May not be done until you make a decision or may be done in a different manner or may be skipped. The first doctor is not going to give you a shot unless the argument is so compelling that you agree with it on first visit.
Posted 2/8/2020 2:53 PM (GMT 0)
My layman opinion is that you are very unfavorable intermediate bordering on high risk. The high volume cores mean the cancer is at the capsule and maybe even out. You dx is similar to mine, I just had a higher PSA, but both show a boatload of G4. You treat the G4 and disregard the G3. Though I usually favor a read by Epstein, I am not sure it would make any meaningful difference in a treatment approach.

As to ADT, if you are going to use radiation as a an initial treatment, then you could start right after the scans. If you are going to have surgery and then probably salvage or adjuvant radiation, then you would start ADT after the surgery. Rarely does one have ADT before surgery as it changes the prostatic tissue and make difficult surgery even more so. If the scans show Mets, then it means systemic treatment and possibility debulking of the source, often by using radiation to lessen side effects.

Your next meeting will give you the information to decide on a treatment direction and sequence.
Posted 2/27/2020 4:17 PM (GMT 0)
Well, that was an interesting and tortuous couple weeks...

Bone and CT scans each showed suspicious lesions, but in different places. Oh crap...

Axumin PET scan finally conducted this week with a negative finding: "No suspicious extraprostatic uptake is detected."

At last, a happy surprise in this process.

I may start a new thread to pose this question, but I'm now reconsidering surgery as a primary treatment option, with the negative PET scan. I know there may well be micromets even an Axumin scan would miss, but there now seems somewhat higher confidence that the horse may still be in the corral. Basically, how (if at all) to factor in a clear Axumin PET scan into the primary treatment decision?
Posted 2/27/2020 4:59 PM (GMT 0)
Freewill,

It may be that cure is still possible in your case--that being said, and even though I get listed as one of the "surgery guys" on this forum (Yes, I'm a surgery patient, but I do not advocate beyond saying that I had an excellent outcome and get irritated when some state unequivocally that surgery "always" is a bad deal)--I strongly believe that surgery is rarely indicated in higher risk situations, simply because it's not really known whether you are really totally confined.
Posted 2/27/2020 5:31 PM (GMT 0)
FW - Good to hear about clear PET scan and yes, the CT scans can tell you things you would rather not know when you are doing the PCa journey. This is why you don't do scans for the heck of it since most other things found are not really important but you are then obligated to check them out at some point.

My thoughts are similar to halbert. I had surgery and then ART due to a worse G score after surgery (only way to know that part for sure is to have gone through prostate removal and pathology examination unfortunately). Surgery is tough sledding for a while but probably easier the younger you are and finding an experienced surgeon to do the work. Radiation is about the same regardless of age although there are some concerns about the effects many years down the road (jury is out on long term effects of newer treatments schemes and equipment) and there are many flavors to choose from.

I might favor radiation for your situation since you are leaning towards the high risk status. A genomic test on your biopsy sample would provide some info of how risky the cancer appears to be for additional info. Surgery would be an option also for your age but the possibility of ART or SRT would be a high probability so you have to deal with that as a possible result. Many have done the multiple radiation treatment schemes and they will chime in shortly with their opinions. Just talk with all the doctors, read the books, and reduce it down to what you think you can deal with best.
Posted 2/27/2020 5:57 PM (GMT 0)
In the highly unlikely scenario that there were micromets that you couldn't see, then I'm not sure how relevant the surgery vs radiation question would be. But what would be more common would be if you had a small amount of local spread--then radiation could make a lot of sense since it treats a wider area. Or surgery plus radiation, but my bias--when faced with the same possibility--was just to cut to the chase and have radiation.

BTW, bone scans are notorious as showing every little injury that you've had over the years show up as suspicious, so I know how scary that process can be. I've seen lots of other guys sweat that out as well...I'm glad that you ended up okay.
Posted 2/27/2020 6:49 PM (GMT 0)
With that extent of cancer in terms of positive cores and percentage in some of the cores bodes poorly for surgery to be curative. Run several nomograms from Johns Hopkins and Memorial Sloan Kettering Cancer Center. The probability of you needing radiation after surgery will be very high.

Understand that salvage radiation is a very different situation than radiation as a primary treatment when it comes to side effects. Surgery plus radiation is something most will want to avoid. For your situation the combination or external beam radiation and brachytherapy has proved to be the best in terms of long term effective cancer control and the lowest expected negative treatment side effects.

Consider these very carefully. Make sure you visit with several radiation oncologists as well as surgeons. My diagnosis was very similar to yours, except my PSA was higher. Three surgeons all said no to surgery because their assessment was that I would also have to have radiation. They did not want to subject me to the increased risk and side effects that surgery plus radiation present.
Posted 2/27/2020 8:49 PM (GMT 0)
Thanks guys (and Halbert, I hope your brother doesn't have to join the club!). I will continue to noodle through this and do my due diligence -- and had already set up some additional RO/MO appts to solicit various points of view.

Cheers
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