Dx in June 2022. Biopsy sampled 11 cores, with one coming back at 5% 3+3 and Gleason 6. But because PSA was 20.5, was eligible for PET PSMA scan, which showed avidity in bones, so now M1B. Have started ADT - lupron + darolutamide (arasec trial, open label).
My question for the group is - what am I to make around all the literature around G6 not having potential for being metastatic? Dr. Walsh book gives a stat of something like 14,000 G6 and zero cases of metasasis. But he also cites that 20-40% of G6 is actually higher. So it's just a sampling error? But I also had just the 1/11 at 5%.
What might this mean for my journery forward? Be as agressive as possible in treatments, or take some time. . .
Wanting to connect to any others on this quality board that might have been G6 but also mPC.
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Heykm01
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1) Your biopsy only sampled a tiny tiny fraction of your prostate
2) if someone else looked at your biopsy they may rate it a higher grade. The entire process a pathologist is involved in can be somewhat subjective. Oftentimes people send their slides to Johns Hopkins to get a second opinion from Epstein's lab.
3) Our knowledge is imperfect. Many of the "rules" in medical science are reflective of what happens most of the time, but not all of the time. There may be other things besides gleason score/grade that we are simply unaware of.
4) They made a mistake transcribing the results of your biopsy.
At this point though, if there was some avidity on a bone and that is *confirmed*, you must assume it is real and that is actual truth. Unfortunately your cancer does not care how someone performed, or interpreted the results of, your biopsy. If there is a met there is a met.
On the other hand the good news is they went looking for more with a PSMA Pet so you will now be treated appropriately.
The data your mentioned was obtained in patients studied with CT and bone scans, two procedures with a very low detection rate when compared with the PSMA PET/CTs.
. You may not have any met visible in a CT or a Bone scan but they are visible in a PSMA PET/CT.
A large % of patients who were in the non metastatic castration resistant cancer (diagnosed with CT and bone scans) and apalutamide , had metastases when they were studied with a PSMA PET/CT.
In 2011, I was diagnosed with GS 3+3 prostate cancer and had brachytherapy. Five years later, I had extra-capsular recurrence in a large 1 inch diameter ball attached to the prostate capsule. The biopsy was not graded but appeared to be of higher grade GS 8 or 10 . Now I have metastatic cancer in many lymph nodes.
Obvious explanation, biopsy can miss higher grade cancer. The lesson I learned never treat GS 3 +3 diagnosis lightly.
Prostatic adenocarcinoma, Gleason score 3 + 3 = 6 (Grade group 1), involving 5% of one core. (See Note and Comment). Note: The triple immunostaining on Part Creveals AMACR immunoreactivity and the absence of basal cells (negative p63 and high molecular weight cytokeratin staining) in the morphological abnormal glands, supporting the above the diagnosis. The Part C was reviewed at the Intradepartmental Quality Assurance Conference and those present concur with the above diagnosis.
TRUS BIOPSIES should be eliminated (banned) and replaced with at least a FREE 3TmpMRI scan, with added non invasive tests and then a guided-targeted trans-perineal biopsy. just my 2 cents
I don’t know the size of your prostate. Mine was 80 cm and I had 18 sticks. Gleason 7(4+3). With 10 sticks and your PSA as high as it is, it just means cancer cells were probably missed. This is often the case when a couple biopsies reflected the no cancer. Your PSA is indicative of a strong possibility of metastatic disease. Good luck in killing the little bastards with your primary treatment.
MO thinks a false positive is a possibility, but from what I've read that isn't like in bone metatasis. We are proceeding of course as if it is real and MO says time will reveal if it turns out false positive.
MRI 86 cm^3 and showed one PIRADS 3 lesion, but cancer was not found in the lesion.
I'm at Northwestern in Chicago. Happy with MO, he's a hopkins guy, very well published. I will be looking for a second opinion in a few weeks but wanted to get started on therapy.
When I was diagnosed with PCa seven years ago, I did not get a bone scan, I got a PSMA PET/CT. It showed affected nodes in the pelvis. This was my mistake, as I was diagnosed with metastases, I got the recommendation for a lifelong ADT therapy. The doctors refused surgery, IMRT, SBRT and Proton beam radiation.
If I would have a got a CT/bone scan this would have been clear. Dr. Nick James said at the ASCO: if the patient shows no metastases using CT/bone scan, he is not metastastic even if the PSMA PET/CT shows mets. All the studies and evidence we currently have is based on CT/bone scan and the guidelines as well. Your MO treats you as if you had bone mets on bone scan. Therefore I think this is overtreatment. Most doctors will treat you as if the PSMA PET/CT results would be CT/bone scan results.
I would ditch the PSMA PET/CT and declare myself unmetastatic. Then get surgery which will also determine the correct Gleason score, or get radiation. Even if you have a few bone mets, radiation of prostate will improve your situation:
This has nothing to do with your MO. He can only go on what the report says. It's the expertise of the interpreter and there can be difference of opinion as these are not all that simple to interpret and a fairly new modality,
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Stage 4 metastatic 
47yrs old 4.46psa Gleason 4+5=9
High Gleason, Low PSA
Oligo Metastatic Prostate Cancer
Metastatic Prostate Cancer (?)
