I had a prostate biopsy on 12-19-2019 following an MRI that showed a "troubling lesion", according to my urologist/oncologist who is a surgeon. He said I would have results in the new year as offices closing over holidays. Two days later, on Saturday, 12-21, he called to say that of the 12 Cores taken, one was cancerous. It was...
Prostate, right medial apex, core biopsy:
Prostatic adenocarcinoma, Gleason 3+4=7 (Prognostic Grade Group
II), measuring 5 mm and occupying 15% of the biopsy core (20-25% pattern
4)
Can anyone give me any insight into what the (20-25% pattern 4) means?? I have investigated it on the internet, but it is very confusing to me. I want to ask the right questions when I see the urologist/oncologists. I understand the Gleason score and the Group II. Any help would be appreciated.
As an aside, my urologist, when I questioned him, said that he might wait and watch, but that I could have it dealt with if I wanted. When questioned as to what he felt would be the best option of treatment, he indicated probably radiation treatment. Obviously, I will discuss with the Doctors when I see them. Thanks for any input or suggestions.
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carlsbadjack
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Gleason Pattern indicates the structure of the tumor for example prsence of cribriform glands which are more aggressive than other structures of GP 4 the presence of cribriform glands appears to be associated with the worst clinical course. It’s found that the presence of cribriform glands was associated with decreased 5-year biochemical recurrence free survival when compared with GS 7 cancers without this architecture.
Briefly it means that most of men has Gleason score of 7 but in clinical term you see they behave differently although 7 Gleason is considered as intermediate aggressiveness ,It is safe to say that somehow Gleason pattern is considered as subtype of Gleason score(although my sentence is not really correct) it means that your doctor first consider your Gleason score for prediction of the cancer behavior and then he looks deeper in your Gleason pattern to see if you are a patient with low Gleason score that can be kept safely under active surveillance or your doctor should treat you more aggressively to reduce the risk of relapse . And in your case you have relatively low Pattern 4 which means if you are stage 3 your doctor must be less warned But hopefully your cancer is still contained and will be cured by prostatectomy
Thanks Annie1373. What does stage refer to? The "Grade" I am a II) or is it something else. I did not see a "stage" in what the biopsy report said. Thanks again.
Stage I: Cancer in this early stage is usually slow growing. The tumor cannot be felt and involves one-half of 1 side of the prostate or even less than that. PSA levels are low. The cancer cells are well differentiated, meaning they look like healthy cells.
Stage II: The tumor is found only in the prostate. PSA levels are medium or low. Stage II prostate cancer is small but may have an increasing risk of growing and spreading.
Stage III:These all indicate a locally advanced cancer has broken through the capsule (covering) of the prostate gland. It may have spread into tubes that carry semen (seminal vesicles) to cancer that is likely to grow and spread.
Stage IV: The cancer has spread beyond the prostate.including lympnodes and bones and viscerals
Overally stage 1 and 2 can be cured stage 3 patients can hopefully live for many years by using hormone deprivation medications or sometimes chemotherapy
The same treatment of ADT plus chemo is available for stage IV .unfortunately there’s no complete cure for Stage IV but available treatments can lengthen the lifespan , by the way I know a lot of man who live with Stage IV cancer for like 10 years or even more so prostate cancer Stage IV doesn’t necessarily mean that the person will die soon and lose hope.We don’t know the future and fortunately there are many new medicines under investigation in recent years for prostate cancer for example olaparib or Lu177 wasn’t available till these recent years.I hope you a long and happy life because as I read your posts I realized that your disease isn’t super advanced, fortunately so why shouldn’t we assume that you will have a long life?
Understandably so. Yeh, I was originally DX’d PCa July 2005. That’s a long long time ago. I was just 53. But the rest of my body was just waiting to explode!! Bang I was Dx’d Super poly-neuropathy 2009, severe cardiomyopathy 2008 and then the heart issues multiplied. Shortness of breath dizzy spells, slight fainting, headaches, not sleeping, so after calling my PCP doc May12,2011 his nurse said you’d better get someone to take me to nearest hospital ER or call 911. I drive to our local hospital ER it’s right across the road, can even see the ER entrance through the trees sometimes. Sudden Carduac Arrested 4 hours later in the ER.
My electrolytes Potassium, Magnesium, every mineral body chemical was extremely low or nil. ER RNs CPR’d me shocked me I don’t know how many times. Then 12 days in CICU. 5 days post SCA I reluctant had my 1st ICD/Pacemaker implanted, not fun but I didn’t even know it. I was do heavily sedated and on an intubation tube for 4 days. It took 5 more days of cardiac rehab, then home for a month of recovery. Note all this time since 2008- early 2013 I was on. ADHT LUPRON DEPOT + double dose if bicalutamide meds. They say ADT therapy meds may have contributed to my SCA. My primary SCA Dx was “ NSVT” non-sustained ventricular tachycardia. Cause::; long term ALCOHOLISM use. I had ceased drinking exactly 3 months prior to my SCA, 90 days and I thought I was cured. Then bang my heart arrested..
Was it combination of long term heavy alcoholism or ADT Meds or both??
Do you think I’m still worried 😧 about Prostate Cancer drugs going into my body? YEAH. Like Abiraterone and Lupron and Prednisone and bicalurimide Yeah.
Thx so for support Annie1373...
Depotdoug
The Gleason number in a scale 1-5 characterizes the type of optical pattern the pathologist saw in the microscope.
The Gleason score represents the addition of the two dominant patterns.
In your case the minority 20-25% was recognized as compliant to Gleason pattern 4 and the majority approx. 75-80% as pattern 3. The approximation has to do with tertiary patterns of 2 or even 5 of a smaller percentage.
Consequently:
GS of 3+3=6 means uniform or more than 95% pattern 3
GS of 3+4 =7 means majority pattern 3 with a portion of pattern 4 (your case)
GS of 4+3 =7 means majority pattern 4 with a portion of pattern 3 (closer to 4+4=8 than to 3+4=7)
In med parlance your case is of the "favourable intermediate risk" stage.
Yet, staging only from biopsy is prone to errors mostly by under-staging and less often by up-staging. From the MRI report you must have got a PIRADS grade.
This is also indicative of your situation and the combination of the two is better than either of them alone.
Basically, they try to estimate the same thing, but to avoid disputes they deliberately introduce confusion by using different scales as there is no one-to-one equivalence due to the large margin of error of both methods.
Its like two antique merchants selling grain one by the bushel the other by the caring capacity of a loaded donkey. None of them can be accurately converted to kilos or pounds.
Reviewed MRI and this is what it said. So I am thinking mine is probably a better chance at aggressiveness.
Impression
IMPRESSION:
1. Overall diffusely heterogeneous and no abnormal signal within the prostate. Underlying prostatitis within the differential.
2. More focal areas of nodularity and signal abnormality are noted both within the anterior transitional zone as well as within the posterior peripheral zone. These areas are PI-RADS 5
Having this MRI report why your dr didn't go for a targeted* biopsy instead of the trivial 12 core one? Irresponsible or too old school?
(*) another common name is fusion biopsy because 3D MRI images are fused with 2D real-time images from the UltraSound machine in an effort to sample the detected "suspicious" areas.
"....We sought to determine the number and location of cores needed to adequately detect clinically significant prostate cancer (PCa). We identified patients undergoing MRI-US fusion prostate biopsy at our institution for known history or clinical suspicion of PCa. Multiparametric MRI studies were reviewed using Likert and Prostate Imaging Reporting and Data System (PI-RADS) v2 schema. Multiple targeted cores were taken from each ROI followed by 12-core systematic biopsy. In a distinct cohort of patients, lesions were targeted using a predetermined five-core template. We estimated cancers detected through sampling of five or fewer cores, assessed by core number and core location....."
"....PATIENT SUMMARY: We aimed to understand how the number of cores obtained from a suspicious area during prostate magnetic resonance imaging-ultrasound fusion biopsy affects cancer detection. We found that sampling of five cores missed substantially fewer cancers compared to two cores...."
I fear that you only had the standard protocol 12-core biopsy.
You have to see specialists in each kind of therapy you are eligible for. Avoid asking a specialist "what is the best" or "what would you do." It is a lot of work, but you have plenty of time and you are worth it. The GS 3+4 with 20-25% pattern 4 means that the cancerous part of that biopsy core (15 % of the core had any cancer in it) comprised 75-80% pattern 3 (the lowest possible) and 20-25% pattern 4. Some patients elect active surveillance even with a small amount of pattern 4. If that is a route you wish to consider, you should get a genomic test done (Prolaris, Oncotype Dx, or Decipher).
At the end of this article are links to questions you might want to ask of various specialists.
For your type of prostate cancer, which is probably "favorable intermediate risk" (I'm assuming your PSA<10 and nothing felt on DRE) there are many good therapies, all having about equal cure rates but differing in side effects. They include surgery, SBRT and either kind of brachytherapy (as monotherapies).
Thank you for your response Tall_Allen. It is much appreciated, and I was hoping you might respond as I find your input on others questions top notch. 3 years ago, my PSA was high, a second was high as well, and I was referred to a urologist. Prior to seeing them, I had another PSA done and it was normal. Last year, normal again, this year, it was .1 over at physical (4.6). After seeing doc for physical (where he did a DRE, subsequent PSA was up to 7.6, a week later 6.6 and again referred to a urologist. PSA prior to visit came back normal. Nothing has ever been noted on DRE's except for prostate slightly enlarged.
As far as treatment, I would like to avoid surgery if possible. I am soon to be 70 (wow, hard to type that number!!!) and the side effects are troubling in many instances. Naturally, I would like to do wait and watch, but will listen to the urologists input. I am with Scripps, and my urologist said that they will be setting up a consultation with him (a surgeon) and a different urologist that is a radiologist. We will then consider the options. My brother will be attending as well, as he was diagnosed with aggressive PC 7-8 years ago. I am looking into the other types of treatment you mentioned.
In San Diego, I suggest you talk to Don Fuller about SBRT (or if you want to come up to LA, my RO, Chris King, is the best). For HDR brachy, I suggest you talk to Mitch Kamrava at Cedars-Sinai.
I suspect Rossi at Scripps will push protons. I think protons works just as well as any other kind of external beam radiation, no better, no worse. It is, however, expensive and often not covered by insurance. It is also tedious because there are so many treatments compared to SBRT. In spite of claims that the Bragg's peak limits toxicity, it does not seem to be the case. A randomized comparison has not been done:
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